Inspection Reports for The Hickman
400 N. WALNUT STREET,, WEST CHESTER, PA, 19380
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
194% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
60% occupied
Based on a January 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 75
Capacity: 125
Deficiencies: 5
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/25/2024 to review compliance and follow-up on a plan of correction submission.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and was a partial unannounced inspection with follow-up on plan of correction submissions.
Findings
The facility was found to have deficiencies related to staff fire safety orientation, incomplete resident medical evaluations, missing annual medical evaluations, and incomplete resident support plan assessments. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Deficiencies (5)
Staff Person A did not receive orientation on evacuation procedures, staff duties during fire drills and emergencies, designated meeting place, smoking safety procedures, use of fire extinguishers, smoke detectors and fire alarms, and telephone use for emergency notification.
Resident medical evaluation did not include a general physical examination and medical information pertinent to diagnosis and emergency treatment.
Resident medical evaluation did not include special health or dietary needs and body positioning and movement stimulation if appropriate.
Resident's most recent annual medical evaluation was incomplete or not timely.
Resident support plan assessment was missing determination for irritability, judgement, agitation, aggression, and hallucination and did not indicate if the resident had a need for these or how the need would be met.
Report Facts
License Capacity: 125
Residents Served: 75
Memory Care Unit Capacity: 26
Memory Care Unit Residents Served: 21
Hospice Residents: 6
Total Daily Staff: 114
Waking Staff: 86
Residents with Mobility Need: 39
Inspection Report
Complaint Investigation
Census: 77
Capacity: 125
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as a result of an incident, with a partial, unannounced inspection type.
Complaint Details
The inspection was incident-related, but no deficiencies or citations were found, indicating no substantiated complaints.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 77
License Capacity: 125
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 7
Residents Age 60 or Older: 77
Residents with Mobility Need: 39
Inspection Report
Follow-Up
Census: 74
Capacity: 125
Deficiencies: 17
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a follow-up review to verify the implementation of a previously submitted plan of correction, triggered by renewal and complaint reasons.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were identified related to privacy, staff training, food safety, fire drills, medication management, and resident support plans, all of which had corrective actions accepted and implemented by the facility.
Deficiencies (17)
Cameras throughout the facility recorded video only without signage indicating recording.
Direct care staff person A received only 8.25 hours of annual training in 2022, less than the required 12 hours.
Direct care staff person A did not receive required training on multiple topics including medication self-administration, dementia care, infection control, and others during 2022.
Multiple kitchen mats were piled outside near the dumpster, creating a hazard.
Unlabeled, undated bag of sausage found in the walk-in freezer.
Outdated food items including turkey bag mix dated 09/01/22 and pizzas dated 02/03/22 found in kitchen walk-in fridge.
Accumulation of lint in the lint trap of the second floor dryer.
Fire drills routinely held in the last seven days or last week of the month, not varying days/times as required.
Resident #1's medical evaluation did not include medical diagnoses.
Discontinued medication (Tramadol HCL 50mg) for resident #2 was not removed and continued to be administered.
Resident #3's medication administration record was incomplete for January and February 2023.
Medication administration record for resident #2 lacked initials of staff administering medication on 05/26/23 at 5pm.
Resident #2's discontinued medication order was not followed; medication was administered after discontinuation without proper reporting.
Residents #1 and #4 were not educated on their right to refuse medication if they believed there was a medication error.
Resident #2's support plan did not document how high fall risk needs would be met.
Resident #2 was unable to sign the support plan and no notation of inability to sign was documented.
Direct care staff person A had only 0.25 hours of dementia care training in 2022, less than the required 6 hours.
Report Facts
License Capacity: 125
Residents Served: 74
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 4
Direct Care Staff Total Daily Hours: 116
Direct Care Staff Waking Hours: 87
Training Hours Received by Staff Person A: 8.25
Training Hours in Dementia Care for Staff Person A: 0.25
Inspection Report
Routine
Deficiencies: 0
Date: Nov 10, 2022
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 or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 74
Capacity: 125
Deficiencies: 20
Date: Mar 14, 2022
Visit Reason
The inspection was conducted as a renewal inspection of THE HICKMAN facility on 03/14/2022 and 03/15/2022 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked poisonous materials, uncovered trash receptacles, hot water temperature exceeding limits, missing emergency telephone numbers, expired elevator certificates, inoperable bedside lamp, lack of thermometers in freezers, insufficient emergency food and water supply, missing rabies vaccination certificate for a resident's cat, missing fire safety inspection, and various medication administration and documentation issues. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (20)
Unlocked cabinet with poisonous materials in secure dementia care unit bedroom J217.
Trash can in Memory care kitchen did not have a lid.
Hot water temperature in bathroom J219 was 125.2°F, exceeding the 120°F limit.
No emergency telephone numbers posted by telephones in Bedroom J105, Memory care kitchen, and 3rd floor personal care kitchen.
Three elevators lacked current certificates of operation from the Department of Labor and Industry or local authority.
Inoperable bedside lamp in bedroom J219.
No thermometer in memory care freezer, 3rd floor personal care freezer, and main kitchen ice cream freezer.
Nine opened and unsealed ice creams in 3rd floor personal care kitchen freezer.
Insufficient emergency drinking water supply; only 90 gallons available for 74 residents requiring 222 gallons.
No current rabies vaccination certificate for resident 11's cat.
No fire safety inspection observed by a fire safety expert from 3/4/2019 through 2/28/2022.
Medication administration errors including removing medication from blister pack away from resident and unlocked medications in resident rooms.
Loose pills found in 2nd floor medication cart.
Discontinued and expired medications found in medication carts.
Medication labeling errors including mismatched controlled substance log and medication label.
Missing preadmission screening forms or incomplete forms for residents.
Delayed or missing medical evaluations and support plans for residents.
Resident records missing hair color, eye color, identifying marks, and photographs.
Criminal background check for staff member not completed prior to hire date.
Bathroom in room J219 lacks operable window or ventilation fan; fan is inoperable.
Report Facts
Residents served: 74
License capacity: 125
Secured Dementia Care Unit capacity: 22
Residents served in secured dementia care unit: 22
Hospice residents: 9
Mobility need: 37
Physical disability: 36
Hot water temperature: 125.2
Emergency drinking water supply: 90
Emergency drinking water required: 222
Loose pills: 7
Opened and unsealed ice creams: 9
Total daily staff: 111
Waking staff: 83
Inspection Report
Follow-Up
Census: 72
Capacity: 125
Deficiencies: 5
Date: Dec 27, 2021
Visit Reason
The inspection was a follow-up review conducted off-site on multiple dates to verify the implementation of a previously submitted plan of correction related to medication administration and resident care.
Findings
The facility was found to have fully implemented the plan of correction addressing medication administration errors, including administering medication prescribed for one resident to another and failure to follow prescriber's orders. Continued compliance must be maintained.
Deficiencies (5)
Staff administered Lorazepam 0.25 mg prescribed for resident #2 to resident #1 and documented it incorrectly.
Resident #1 was administered medication prescribed for resident #2, violating prescription use rules.
Resident #1's family member requested pain medication, but staff administered medication prescribed for resident #2.
Resident #2's vital signs were not checked during the overnight shift on 12/23-24/2021 as prescribed.
Resident #1 was administered Lorazepam 0.5 mg gel for agitation as needed, but it was used as a chemical restraint to control behaviors on specified dates.
Report Facts
Inspection Dates: 4
Staffing: 112
Staffing: 84
License Capacity: 125
Residents Served: 72
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Residents with Mobility Need: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed letter confirming plan of correction implementation |
Notice
Capacity: 125
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Hickman Personal Care Home following receipt of the renewal application dated December 2, 2020.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations. No deficiencies or enforcement actions are noted in this document.
Report Facts
Maximum capacity: 125
Secure Dementia Care Unit capacity: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonetta M. Kelly | Administrator | Recipient of the renewal license notification |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 70
Capacity: 125
Deficiencies: 8
Date: Feb 8, 2021
Visit Reason
The inspection was conducted as a renewal inspection of THE HICKMAN facility to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies related to criminal background checks, staff qualifications, staff orientation, direct care training, bathroom ventilation, fire extinguisher inspection, and first aid kit contents. Plans of correction were accepted and implemented for all deficiencies, with some violations withdrawn upon further review.
Deficiencies (8)
Criminal background checks were not completed timely for multiple staff persons.
Direct care staff persons F and G did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry at the time of inspection.
Staff person E did not receive required fire safety and emergency preparedness orientation until 1/18/21.
Ancillary staff person B did not have a general orientation to specific job functions prior to working in that capacity.
Direct care staff person G began providing unsupervised ADL services without completing required initial direct care training and competency test.
The bathroom on the 1st floor near mailboxes lacked operable window or ventilation fan; fan was inoperable.
Fire extinguisher in the van had not been inspected by a fire safety expert since 2018.
First aid kit in the van used to transport residents did not include tweezers and adhesive bandages.
Report Facts
License Capacity: 125
Residents Served: 70
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 9
Residents with Mobility Need: 36
Residents with Physical Disability: 36
Total Daily Staff: 106
Waking Staff: 80
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