Inspection Reports for The Pinnacle at Plymouth Meeting
215 Plymouth Rd, Plymouth Meeting, PA 19462, United States, PA, 19462
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Inspection Report
Follow-Up
Census: 104
Capacity: 138
Deficiencies: 1
Oct 2, 2025
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction related to facility compliance.
Findings
The plan of correction was determined to be fully implemented, with continued compliance required. A deficiency was noted regarding the lack of a system to safeguard resident laundry, causing delays and loss of personal belongings, which has since been addressed with a new laundry management system and staff training.
Deficiencies (1)
| Description |
|---|
| The home does not have a system to safeguard resident laundry from loss, resulting in residents occasionally waiting over three days for their personal belongings to be returned, with some items going missing. |
Report Facts
License Capacity: 138
Residents Served: 104
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 45
Residents Age 60 or Older: 104
Inspection Report
Complaint Investigation
Census: 100
Capacity: 138
Deficiencies: 10
Jul 28, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to complaint and incident reasons, including multiple on-site and off-site review dates.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, failure to provide required assistance with activities of daily living, incomplete criminal background checks, incomplete staff contact lists, inadequate fire safety orientation for new staff, insufficient hot and cold water in a resident shower, delayed return of residents' clothing after laundering, and medication administration errors including failure to witness ingestion and improper documentation. Plans of correction were accepted and implemented by mid-October 2025.
Complaint Details
The inspection was complaint-related, triggered by complaints and incidents including confidentiality breaches, failure to assist residents as per support plans, and medication administration errors. The plan of correction was fully implemented as of October 15, 2025.
Deficiencies (10)
| Description |
|---|
| Resident medical information was left unlocked and unattended on a medication cart. |
| Resident did not receive required assistance with peri-care and disposal of incontinent products during a shift. |
| Criminal background check for a staff person was completed over one year prior to hire. |
| Administrator's staff list did not include substitute and contracted agency staff. |
| Staff person did not receive required fire safety and emergency preparedness orientation on first day. |
| Shower in a resident's room lacked sufficient hot and cold water due to broken shower head. |
| Resident towels were missing for three days and were returned late after laundering on a different floor. |
| Staff handed medication to resident but did not witness ingestion as required. |
| Medication was documented as administered at 9 AM but was actually handed to resident at 10:45 AM without witnessed ingestion. |
| Resident participated in support plan development but did not sign the support plan. |
Report Facts
License Capacity: 138
Residents Served: 100
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents Diagnosed with Mental Illness: 44
Residents with Mobility Need: 67
Residents Age 60 or Older: 100
Inspection Report
Complaint Investigation
Census: 97
Capacity: 138
Deficiencies: 2
Jul 7, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident at the facility.
Findings
Two deficiencies were identified: one involving an unlabeled bottle of OTC medication belonging to a resident, and another involving the unavailability of a prescribed PRN medication in the home. Both deficiencies had plans of correction accepted and were implemented by 09/24/2025.
Complaint Details
The inspection was triggered by a complaint and incident, as stated under Inspection Information on page 2.
Deficiencies (2)
| Description |
|---|
| A bottle of OTC medication belonging to a resident was not labeled with the resident's name; the label print had worn away completely. |
| A prescribed PRN medication was not available in the home. |
Report Facts
License Capacity: 138
Residents Served: 97
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 16
Current Residents in Hospice: 7
Residents Age 60 or Older: 97
Residents with Mobility Need: 31
Total Daily Staff: 128
Waking Staff: 96
Inspection Report
Enforcement
Census: 80
Capacity: 138
Deficiencies: 37
Apr 28, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, provisional, and incident investigation with multiple on-site visits between April 28 and June 25, 2025.
Findings
The facility was found to have multiple violations including failure to report suspected abuse, inadequate supervision and suspension of staff involved in abuse allegations, failure to report incidents timely, resident neglect, confidentiality breaches, improper medication management, unsafe storage of poisonous materials, unsanitary conditions, and deficiencies in staff training and documentation. Several repeat violations were noted. Plans of correction were accepted but many were not implemented as of the follow-up dates.
Complaint Details
The complaint investigation found substantiated allegations of abuse, neglect, financial exploitation, and failure to provide adequate care and supervision. Specific incidents included physical altercations between staff and residents, unauthorized financial transactions, failure to report abuse, and neglect of residents' incontinence needs. The facility was issued a second provisional license with required plans of correction.
Deficiencies (37)
| Description |
|---|
| Failure to immediately report suspected abuse incidents to the Area Agency on Aging and Department. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse incidents. |
| Failure to timely report incidents or conditions to the Department’s regional office within 24 hours. |
| Failure to inform residents or their designated persons of validated incidents immediately following investigation. |
| Resident records confidentiality breach with unlocked laptop accessible to residents and visitors. |
| Failure to complete resident-home contracts timely and obtain signed statements acknowledging receipt of resident rights. |
| Resident abuse including physical altercations between staff and residents, resulting in injuries and hospitalizations. |
| Resident neglect related to unmet incontinence needs and inadequate overnight care. |
| Failure to secure poisonous materials accessible to residents in the Secure Dementia Care Unit. |
| Unsanitary conditions including lack of paper towels and overflowing trash dumpsters. |
| Failure to maintain clean surfaces such as stairwell doors. |
| Missing emergency telephone numbers posted by telephones. |
| Resident bedroom deficiencies including stained mattresses, missing bedside tables, and lack of operable bedside lamps. |
| Failure to provide toilet paper in common bathrooms. |
| Accumulation of lint in clothes dryer lint traps creating fire hazards. |
| Failure to maintain current rabies vaccination certificates for resident pets. |
| Blocked egress due to locked exit gate with malfunctioning key fob in memory care courtyard. |
| Combustible materials stored near heat sources in elevator control room. |
| Failure to post current weekly menus in a conspicuous location. |
| Failure to assess resident ability to self-administer medications and maintain current medication lists. |
| Failure to keep prescription medications locked and secure, including unattended medication carts. |
| Presence of discontinued medications in medication carts. |
| Improper storage of medications including unlabeled and expired insulin pens. |
| Transcription errors in blood glucose logs. |
| Failure to follow prescriber's medication orders, including missed doses and glucose checks. |
| Use of prohibited procedures including manual restraint and chemical restraint during resident behavioral incidents. |
| Failure to complete resident assessments timely and update support plans for significant changes. |
| Failure to assess and address resident mobility needs in assessments. |
| Failure to obtain signatures on support plans from residents or their representatives. |
| Failure to develop and implement admission support plans within required timeframes. |
| Failure to provide required dementia care training to direct care staff in the Secure Dementia Care Unit. |
| Failure to make resident records available to residents or their designated persons upon request. |
| Failure to safeguard resident money and property with secure, uniquely keyed drawers and key control. |
| Failure to respond timely to resident call bell system, resulting in excessive wait times for assistance. |
| Incomplete annual medical evaluations missing required signatures and dates. |
| Medication records missing required information including diagnosis or purpose for medications. |
| Failure to complete preadmission screening forms within required timeframe prior to admission. |
Report Facts
License Capacity: 138
Residents Served: 80
Residents Served: 84
Secure Dementia Care Unit Capacity: 19
Secure Dementia Care Unit Residents Served: 18
Secure Dementia Care Unit Residents Served: 15
Current Hospice Residents: 7
Resident Wait Time Over 20 Minutes: 17
Resident Wait Time Over 20 Minutes: 2
Fine Amount: 420
Fine Per Resident Per Day: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Involved in resident abuse incidents including pushing Resident 1 causing a fall. | |
| Staff Person B | Received reports of abuse incidents but failed to report to authorities. | |
| Staff Person C | Involved in physical altercation with Resident 1 and failed to report abuse. | |
| Staff Person D | Involved in abuse incidents and failed to report; did not receive required dementia training. | |
| Staff Person E | Received abuse reports but did not report to authorities; no longer employed. | |
| Staff Person F | Involved in alleged abuse/theft incident; suspended and returned to work prematurely. | |
| Staff Person G | Responded to resident altercation incident. | |
| Staff Person H | Assisted resident after injury; involved in neglect incidents. | |
| Staff Person I | Reported neglect incidents in memory care unit. | |
| Staff Person J | Reported neglect incidents in memory care unit. | |
| Staff Person K | Reported resident found soaked in urine. | |
| Staff Person L | Reported urine soaking through mattress and pooling on floor. | |
| Staff Person M | Did not receive required fire safety orientation on first day of work. | |
| Staff Person N | Refused to provide resident records upon request. | |
| Juliet Marsala | Deputy Secretary | Signed licensing letters and notices. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 138
Deficiencies: 44
Apr 28, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit for renewal, complaint, provisional, and incident reasons, including follow-up on plan of correction submissions.
Findings
The inspection identified multiple violations including resident abuse, failure to report abuse, inadequate supervision plans, confidentiality breaches, medication management issues, neglect in care related to incontinence, unsafe storage of poisonous materials, sanitary deficiencies, fire safety training lapses, and incomplete resident assessments and support plans. Several repeat violations were noted. Plans of correction were accepted but many were not implemented as of the follow-up dates.
Complaint Details
The complaint investigation revealed multiple allegations including financial abuse, neglect, verbal abuse, and failure to provide care. Specific incidents involved missing resident funds, refusal to assist residents with care, and failure to report abuse to the appropriate agencies. The facility was found noncompliant with reporting and care standards.
Deficiencies (44)
| Description |
|---|
| Failure to immediately report suspected abuse incidents to the Area Agency on Aging. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse incidents. |
| Failure to report incidents to the Department within 24 hours as required. |
| Failure to inform residents or their designated persons of validated incidents of financial exploitation immediately following investigation. |
| Resident records confidentiality breach due to unlocked laptop displaying resident information. |
| Resident-home contract not completed timely for a resident. |
| Resident did not have a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident abuse involving physical altercations between staff and resident causing injury and hospital admission. |
| Unauthorized financial transactions and theft of resident property compromising resident trust. |
| Neglect related to unmet incontinence care needs and failure to provide adequate overnight care. |
| Failure to provide fire safety orientation to staff on first day of work. |
| Direct care staff did not receive required annual training on medication self-administration and fire safety. |
| Staff training plan did not include required details such as staff names, required trainings, and schedules. |
| Poisonous materials left unlocked and accessible to residents not assessed as safe to use or avoid poisons. |
| Sanitary conditions not maintained; paper towels missing in common bathroom. |
| Trash dumpsters overflowing with lids unable to close fully. |
| Floors, walls, ceilings, doors not clean; dried brown substance smeared on stairwell door. |
| Emergency telephone numbers not posted on or by telephone in resident room. |
| Resident bed mattress stained and uncovered; no bedside table or shelf; no operable lamp at bedside. |
| Toilet paper not provided in common bathroom. |
| Lint accumulation in clothes dryer lint traps. |
| Cats present without current rabies vaccination certificates on file. |
| Locked exit gate in memory care courtyard was inaccessible due to key fob malfunction, blocking egress. |
| Combustible aerosol can stored near electrical box in elevator control room. |
| Menus not posted for current and following week in a conspicuous location. |
| Resident self-administration medication assessment not completed by physician or designee. |
| Resident medication record not current or complete; missing medications and incorrect doses. |
| Medications and syringes not locked; medication cart left unattended with pills unsecured. |
| Discontinued medications kept in medication cart. |
| Opened insulin pen not labeled with date opened; expired insulin pen present. |
| Errors in transcription of blood glucose readings in resident logs. |
| Failure to follow prescriber's orders for medication administration and glucose monitoring. |
| Prohibited procedures used including manual restraint and chemical restraint for behavior control. |
| Resident assessments not completed timely or updated for significant changes. |
| Resident assessments and support plans not signed by residents or properly documented. |
| Initial support plan for secured dementia care unit resident not completed within 72 hours of admission. |
| Direct care staff in secured dementia care unit lacked required dementia care training hours. |
| Resident records not made available to resident or designated person upon request. |
| Resident care neglect including failure to assist with toileting and personal hygiene, and delayed staff response to call bells. |
| Failure to provide secure system for safeguarding resident money and property; keys not tracked or controlled. |
| Staff call bell policy not followed; residents experienced excessive wait times for staff response. |
| Incomplete annual medical evaluations with missing required fields and signatures. |
| Medication records missing diagnosis or purpose for medications. |
| Preadmission screening forms not completed within 30 days prior to admission. |
Report Facts
License Capacity: 138
Residents Served: 80
Residents Served in Secure Dementia Care Unit: 18
Hospice Residents: 7
Residents 60 Years or Older: 96
Residents with Mobility Need: 31
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Inspection Dates: 8
Fines Proposed: 420
Residents Served: 84
Residents Served in Secure Dementia Care Unit: 15
Staffing Hours - Total Daily Staff: 119
Staffing Hours - Waking Staff: 89
Call Bell Response Delays: 17
Call Bell Response Delays: 2
Inspection Report
Follow-Up
Census: 96
Capacity: 138
Deficiencies: 8
Mar 26, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to a complaint and incident, to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including expired fire extinguishers, incomplete medical evaluations, missing determinations on preadmission screening forms, unsigned support plans, and outdated support plans. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Complaint Details
The inspection was triggered by a complaint and incident, as stated in the inspection information section.
Deficiencies (8)
| Description |
|---|
| Thirty fire extinguishers failed to be approved by a fire safety expert due to passing the 6-year expiration period. |
| Resident's most recent medical evaluation did not include Health Status/Cognitive Functioning. |
| Resident and preadmission screening forms did not include a determination that the needs of the residents can be met by the services provided by the home. |
| Resident participated in the development of support plan but did not sign the support plan. |
| Resident assessment and support plan was not signed by the resident and no notation of refusal or inability to sign was documented. |
| Resident's medical evaluation did not include diagnosis of dementia or other required information for Secured Dementia Care Unit admission. |
| Resident's written cognitive preadmission screening was completed after admission to the secured dementia care unit. |
| Resident's support plan was not updated after returning from hospital with an indwelling catheter. |
Report Facts
Total Daily Staff: 131
Waking Staff: 98
Residents Served: 96
License Capacity: 138
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 19
Residents Age 60 or Older: 94
Residents with Mobility Need: 35
Inspection Report
Follow-Up
Census: 68
Capacity: 138
Deficiencies: 6
Oct 16, 2024
Visit Reason
The inspection was an unannounced partial visit conducted due to a complaint and incident, to review the facility's compliance and the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including resident abuse and neglect, improper treatment of residents, direct care staff lacking required qualifications and training, and incomplete medication records. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Complaint Details
The inspection was complaint-related and incident-based, as indicated by the reason for the visit and the findings related to resident abuse and neglect.
Deficiencies (6)
| Description |
|---|
| Resident reported missing money from purse kept in bedroom; resident was unaware of locked drawer for safeguarding possessions. |
| Agency staff person A treated resident with hostility and intimidation, causing discomfort. |
| Direct care staff person B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A did not receive orientation on fire safety and emergency preparedness topics on first work day. |
| Direct care staff person B provided unsupervised ADL services without completing required training and competency test. |
| Resident medication list did not include a current list of prescription, CAM, and OTC medications for a self-medicating resident. |
Report Facts
License Capacity: 138
Residents Served: 68
Memory Care Capacity: 19
Memory Care Residents Served: 17
Current Hospice Residents: 4
Residents with Mobility Need: 46
Residents Age 60 or Older: 1
Resident Support Staff: 0
Total Daily Staff: 114
Waking Staff: 86
Inspection Report
Follow-Up
Census: 83
Capacity: 138
Deficiencies: 22
Jun 3, 2024
Visit Reason
The inspection was conducted as a follow-up visit to verify correction of previous deficiencies, complaint investigation, incident, and monitoring at The Pinnacle at Plymouth Meeting.
Findings
Multiple deficiencies were found related to resident treatment, privacy, staff hiring, first aid/CPR training, safety, emergency preparedness, medication records, assessments, and abuse reporting. Plans of correction were proposed with various completion dates, some not yet implemented as of the report date.
Complaint Details
The inspection included complaint investigation related to resident abuse, neglect, and financial abuse allegations. Some allegations were not substantiated by the home or local authorities. The home failed to report a missing checkbook incident to the Department.
Deficiencies (22)
| Description |
|---|
| Staff person B yelled at resident #1 and was terminated after the incident. |
| Video recording devices were identified in common areas without proper signage. |
| Staff member C's criminal background check was not completed timely. |
| No staff certified in first aid, obstructed airway techniques, and CPR were present during a night shift with 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials found in Memory Care unit. |
| Trash cans in 3rd and 4th floor men's bathrooms were uncovered. |
| Expired alcohol prep pads found in first aid kit. |
| Resident #1 did not have access to an operable lamp at bedside. |
| Refrigerator and freezer temperatures in Memory Care Kitchenette were above required levels. |
| Staff person C did not have a copy of the emergency preparedness plan for the local municipality. |
| Fire extinguisher inspection tag missing in Memory Care hallway. |
| Fire drill records lacked exact time, evacuation time, and exit routes used. |
| Resident #2's medication record did not include all medications, including those taken before dental appointments. |
| Resident #3 and #4 assessments and support plans were not completed timely. |
| Resident #1's support plan lacked risk information and device identification for bed mobility device. |
| Resident #3's cognitive preadmission screening was not completed. |
| Resident 1 reported missing checkbook; incident not reported to Department. |
| Resident 2 experienced suspected financial abuse with unauthorized checks cashed. |
| Staff person E verbally abused resident 3 and was terminated. |
| Staff person E did not complete mandatory abuse and neglect training within 40 hours. |
| Bathroom cabinet in resident room 103 had a broken handle. |
| Resident 4's initial medical evaluation did not include a list of current medications. |
Report Facts
License Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents Served in SDCU: 13
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Number of Deficiencies: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in resident abuse and verbal abuse incident. | |
| Staff person C | Named in criminal background check violation and emergency preparedness plan violation. | |
| Staff person E | Named in resident abuse incident and termination. | |
| Executive Director | Responsible for multiple plans of correction and staff training. | |
| Wellness Coordinator | Responsible for auditing medical evaluations and assessments. | |
| Assistant Executive Director | Responsible for staff training and audits. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 138
Deficiencies: 22
Jun 3, 2024
Visit Reason
The inspection was conducted due to complaint, incident, and monitoring reasons as part of the Pennsylvania Department of Human Services licensing inspection process.
Findings
Multiple violations were found related to resident rights, staff hiring, safety, privacy, emergency preparedness, medication management, abuse reporting, and documentation. The facility received a provisional license due to these violations and submitted plans of correction with various completion dates.
Complaint Details
The inspection was complaint-related, involving allegations of resident abuse, neglect, and financial exploitation. Some allegations were not substantiated, and the facility was required to report incidents and implement corrective actions.
Deficiencies (22)
| Description |
|---|
| A resident was verbally abused by staff who yelled at the resident and was subsequently terminated. |
| Video recording devices were found in common areas without proper signage, violating privacy regulations. |
| Staff hiring process was deficient with delayed criminal background check completion. |
| No staff certified in first aid and CPR were present during a night shift with approximately 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials found in memory care unit. |
| Trash receptacles in men's bathrooms were uncovered, allowing penetration of insects and rodents. |
| Expired alcohol prep pads found in first aid kits. |
| Resident did not have access to an operable lamp or lighting source at bedside. |
| Refrigerator and freezer temperatures in memory care kitchenette exceeded required limits. |
| Staff member did not have a copy of the emergency preparedness plan for the local municipality. |
| Fire extinguisher inspection tag missing; last inspection date unknown. |
| Fire drill records lacked exact time, evacuation duration, and exit routes used. |
| Resident medication record did not include a current list of medications for a self-medicating resident. |
| Initial resident assessments and support plans were not completed within required timeframes. |
| Resident support plan did not include risks, device identification, or FDA compliance for bed mobility device. |
| Resident abuse incidents were not reported to the Department as required. |
| Resident financial abuse suspected but not reported to designated person. |
| Resident verbally abused by staff with inappropriate language; staff terminated. |
| Staff did not complete mandatory training on abuse and neglect reporting within 40 scheduled hours. |
| Bathroom cabinet had a broken handle. |
| Resident's initial medical evaluation did not include a list of current medications. |
| Resident cognitive preadmission screening was not completed prior to admission to secured dementia care unit. |
Report Facts
License Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents Served in Secured Dementia Care Unit: 13
Current Residents in Hospice: 2
Number of Residents Aged 60 or Older: 83
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 28
Residents with Physical Disability: 0
Staff Certified in First Aid/CPR: 0
Temperature in Refrigerator: 54
Temperature in Freezer: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person E | Named in resident abuse incident where staff used inappropriate language and was terminated. | |
| Staff person C | Named in multiple findings including lack of emergency preparedness plan, witnessing abuse, and hiring violations. | |
| Staff person B | Named in resident abuse and financial exploitation reports. | |
| Executive Director | Responsible for implementing plans of correction and staff training. | |
| Wellness Coordinator | Responsible for auditing medical evaluations and assessments. | |
| Assistant Executive Director | Responsible for staff training and auditing admission pre-screenings. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 138
Deficiencies: 21
Jun 3, 2024
Visit Reason
The inspection was conducted due to complaint, incident, and monitoring reasons as part of a licensing inspection of The Pinnacle at Plymouth Meeting.
Findings
Multiple violations were found related to resident rights, staff hiring, safety, privacy, emergency preparedness, medication management, assessments, and abuse reporting. The facility received a provisional license due to these violations and must correct all deficiencies by specified dates.
Complaint Details
The inspection was complaint-related, with substantiation status not explicitly stated. Multiple abuse and neglect allegations were investigated, including verbal abuse, financial abuse, and failure to report incidents.
Deficiencies (21)
| Description |
|---|
| A resident was verbally disrespected by staff who yelled at them and staff was terminated. |
| Video recording devices were found in common areas without proper signage and notification to residents. |
| Staff member's criminal background check was not completed before hire. |
| No staff certified in first aid and CPR were present during a night shift with 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials found in memory care unit. |
| Trash receptacles in bathrooms were uncovered, allowing insect and rodent penetration. |
| Expired alcohol prep pads found in first aid kits. |
| Resident did not have access to operable lamp or lighting at bedside. |
| Refrigerator and freezer temperatures in memory care kitchen were above required limits. |
| Staff did not have a copy of the emergency preparedness plan for the local municipality. |
| Fire extinguisher inspection tag missing; last inspection date unknown. |
| Fire drill records lacked exact time, evacuation duration, and exit routes used. |
| Resident's medication record did not include a current list of medications. |
| Resident assessments and support plans were not completed timely or were missing. |
| Resident abuse incidents were not reported to the Department as required. |
| Resident received financial abuse; facility failed to notify designated person. |
| Resident was verbally threatened by staff. |
| Staff did not complete mandatory abuse and neglect reporting training within required hours. |
| Bathroom cabinet had a broken handle. |
| Resident's initial medical evaluation did not include a list of current medications. |
| Resident's cognitive preadmission screening was not completed prior to admission to secured dementia care unit. |
Report Facts
Maximum Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents in Secured Dementia Care Unit: 13
Staffing: 111
Waking Staff: 83
Deficiency Count: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in verbal abuse incident and separation from resident. | |
| Staff person C | Named in hiring violation, emergency preparedness violation, and abuse investigation. | |
| Staff person E | Named in verbal abuse incident and terminated after incident. | |
| Executive Director | Responsible for multiple plans of correction and staff training. | |
| Wellness Director | Responsible for medication audits and staff training. | |
| Dining Director | Responsible for refrigerator temperature correction. | |
| Facility Manager | Responsible for fire drill records and key log audits. | |
| Assistant Executive Director | Responsible for staff training and audits of assessments. |
Inspection Report
Enforcement
Census: 83
Capacity: 138
Deficiencies: 22
Jun 3, 2024
Visit Reason
The inspection was conducted as a licensing inspection with reasons including complaint, incident, and monitoring.
Findings
Multiple violations were found related to resident rights, staff hiring, safety, emergency preparedness, medication records, assessments, and abuse reporting. The facility's certificate of compliance was revoked and a first provisional license was issued based on an acceptable plan of correction.
Complaint Details
The inspection was complaint-related, incident-related, and monitoring-related. Specific complaints included resident abuse, financial abuse, and failure to report incidents timely. Some allegations were substantiated with corrective actions planned.
Deficiencies (22)
| Description |
|---|
| A resident was verbally abused by staff who yelled at the resident and was subsequently terminated. |
| Video recording devices were identified in common areas without proper signage, violating resident privacy. |
| Staff hiring process was deficient as a criminal background check was delayed. |
| No staff certified in first aid and CPR were present during a night shift with approximately 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials was found in the memory care unit. |
| Trash receptacles in men's bathrooms were uncovered, allowing penetration of insects and rodents. |
| Expired alcohol prep pads were found in the first aid kit. |
| Resident did not have access to an operable lamp or lighting source at bedside. |
| Refrigerator and freezer temperatures in the memory care kitchenette were above required limits. |
| Staff did not have a copy of the emergency preparedness plan for the local municipality. |
| Fire extinguisher inspection tag was missing and last inspection date could not be determined. |
| Fire drill records lacked exact time, evacuation duration, and exit routes used. |
| Resident medication record did not include a current list of medications and pre-dental medications. |
| Initial resident assessments and support plans were not completed within required timeframes. |
| Resident support plan did not include risks, device identification, or FDA compliance for bed mobility device. |
| Resident cognitive preadmission screening was not completed within required timeframe. |
| Suspected financial abuse involving missing checks was not reported to the Department. |
| Resident was verbally threatened by staff using inappropriate language. |
| Staff member did not complete mandatory training on abuse and neglect reporting within 40 scheduled hours. |
| Bathroom cabinet had a broken handle. |
| Resident's initial medical evaluation did not include a list of current medications. |
| Resident's assessment did not include social activity engagement area. |
Report Facts
License Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents Served in Secured Dementia Care Unit: 13
Current Hospice Residents: 2
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Residents Present During CPR Deficiency: 83
Temperature in Refrigerator: 54
Temperature in Freezer: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person E | Named in resident abuse finding and terminated after incident. | |
| Staff person B | Named in resident abuse and verbal altercation findings. | |
| Staff person C | Named in staff hiring, emergency preparedness, and abuse findings. | |
| Executive Director | Responsible for multiple plans of correction and staff training. |
Inspection Report
Enforcement
Census: 83
Capacity: 138
Deficiencies: 21
Jun 3, 2024
Visit Reason
The inspection was conducted as a complaint, incident, and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including issues with resident treatment, privacy, staff hiring, first aid/CPR training, safety of poisonous materials, trash receptacles, first aid kits, lighting, refrigerator/freezer temperatures, emergency preparedness, fire extinguisher inspection, fire drill records, medication records, assessments, support plans, abuse reporting, and furniture condition. A provisional license was issued due to these violations.
Complaint Details
The inspection was complaint-related with substantiated findings of resident abuse, neglect, and financial exploitation. The home failed to report incidents timely and did not notify designated persons as required.
Deficiencies (21)
| Description |
|---|
| Resident was verbally abused by staff who yelled at the resident and staff person was terminated. |
| Video recording devices were identified in common areas without proper signage and resident contract did not fully disclose surveillance. |
| Staff member's criminal background check was not completed timely. |
| No staff certified in first aid and CPR were present during a night shift with approximately 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials found in memory care unit. |
| Trash cans in men's bathrooms were uncovered. |
| Expired alcohol prep pads found in first aid kit. |
| Resident did not have access to an operable lamp or lighting at bedside. |
| Refrigerator and freezer temperatures in memory care kitchenette were above required limits. |
| Staff did not have a copy of the emergency preparedness plan for the local municipality. |
| Fire extinguisher safety inspection tag missing; last inspection date unknown. |
| Fire drill records lacked exact time, evacuation duration, and exit routes used. |
| Resident medication record did not include a current list of medications. |
| Initial resident assessments and support plans were not completed within required timeframes. |
| Resident abuse incidents were not reported timely to the Department. |
| Resident financial abuse reported but not notified to designated person. |
| Resident verbally threatened by staff; staff terminated. |
| Staff did not complete mandatory training on abuse and neglect reporting within 40 hours. |
| Bathroom cabinet had a broken handle. |
| Resident's initial medical evaluation did not include a list of current medications. |
| Resident's cognitive preadmission screening and support plans were incomplete or late. |
Report Facts
License Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents Served in Secured Dementia Care Unit: 13
Current Residents in Hospice: 2
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Inspection Dates: 6
Deficiency Counts: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in verbal abuse incident and separation from resident. | |
| Staff person C | Named in hiring violation, emergency preparedness plan violation, and abuse incident. | |
| Staff person E | Named in resident abuse incident and subsequent termination. | |
| Executive Director | Responsible for multiple plans of correction and staff training. |
Inspection Report
Follow-Up
Census: 83
Capacity: 138
Deficiencies: 17
Jun 3, 2024
Visit Reason
The inspection was conducted as a follow-up visit to verify correction of previous deficiencies, including complaint, incident, and monitoring reasons.
Findings
The facility was found to have multiple deficiencies related to resident treatment, privacy, staff hiring, emergency preparedness, fire safety, medication records, assessments, and abuse reporting. Several plans of correction were proposed with some deficiencies not yet implemented as of the last follow-up date.
Complaint Details
The inspection included complaint-related issues such as resident abuse reports, missing checkbooks, and failure to report incidents to the Department. Some abuse allegations were not substantiated, and corrective actions including staff termination and training were implemented.
Deficiencies (17)
| Description |
|---|
| A resident was verbally disrespected by staff who yelled at them; staff was terminated. |
| Video recording devices were identified in common areas without proper signage; community posted signs and disconnected video recording in common areas. |
| Staff hiring process deficiency: criminal background check request was delayed. |
| No staff certified in first aid and CPR were present during a night shift with approximately 83 residents. |
| Unattended, unlocked cleaning cart with poisonous materials found in memory care unit. |
| Trash cans in men's bathrooms were uncovered. |
| Expired alcohol prep pads found in first aid kits. |
| Resident did not have access to an operable lamp at bedside. |
| Refrigerator and freezer temperatures in memory care kitchenette were above required levels. |
| Staff member did not have a copy of the emergency preparedness plan. |
| Fire extinguisher inspection tag missing; last inspection date unknown. |
| Fire drill records lacked exact time, evacuation duration, and exit routes used. |
| Resident medication record did not include a current list of medications. |
| Resident initial assessment was not completed within required timeframe. |
| Resident initial support plan was not completed within required timeframe. |
| Resident support plan did not include risks, device identification, or FDA guidelines for bed mobility device. |
| Resident initial support plan for secured dementia care unit was not completed timely. |
Report Facts
License Capacity: 138
Residents Served: 83
Secured Dementia Care Unit Capacity: 19
Residents Served in Secured Dementia Care Unit: 13
Current Hospice Residents: 2
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 28
Residents 60 Years or Older: 83
Inspection Dates: 3
Deficiencies Cited: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in verbal abuse incident and resident abuse report. | |
| Staff person C | Named in multiple findings including emergency preparedness, abuse, and treatment of residents. | |
| Staff person E | Named in resident abuse incident and was terminated. | |
| Executive Director | Responsible for multiple plans of correction and staff training. | |
| Dining Director | Corrected refrigerator/freezer temperature violation. | |
| Facilities Manager | Responsible for audits related to poisonous materials and fire extinguisher tags. | |
| Wellness Director | Responsible for audits related to CPR training and medication assessments. | |
| Assistant Executive Director | Responsible for staff training and audits related to assessments. |
Inspection Report
Renewal
Census: 55
Capacity: 138
Deficiencies: 27
Feb 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection of THE PINNACLE AT PLYMOUTH MEETING facility to verify compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including missing resident signatures on contracts and rights acknowledgments, privacy violations during medication administration, incomplete criminal background checks, missing fire safety orientations and trainings, uncovered trash receptacles, absence of emergency phone numbers, lack of operable bedside lamps, unprotected and outdated food storage, incomplete fire drill records, missing designated meeting place signage, incomplete medical evaluations and assessments, incomplete support plans, and medication storage issues. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (27)
| Description |
|---|
| Resident-home contracts for residents #1, #2, and #3 were not signed by the residents. |
| Resident #2 and #3's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Resident #4 was evaluated by a third party nurse in a common living room area and medication was administered in the living room, violating privacy. |
| Staff person C was hired without a Pennsylvania criminal background check. |
| Staff person C had not completed a Department-approved orientation program. |
| Staff person D did not receive fire safety orientation on the first day of work. |
| Staff person D did not receive annual training in fire safety and falls and accident prevention during 2022. |
| Uncovered trash cans found in Garden House kitchenette and bathroom in room 419. |
| No emergency telephone numbers posted by the telephone in room 116. |
| Resident #5 did not have access to an operable lamp or source of lighting at bedside. |
| Unprotected food items found in dry storage area (macaroni, almonds, parboiled rice) that were opened and unsealed. |
| No thermometer in refrigerator and freezer in 2nd floor activity bistro. |
| Unlabeled, undated food items and frozen products found in dry storage and freezer areas. |
| Fire drill logs missing exit route used, number of staff participating, correct date, evacuation time, number of residents present and evacuated. |
| No designated meeting place away from building or within fire-safe area for fire drills. |
| Medical evaluations for residents #1, #2, #6, and #7 missing immunization history, body positioning/movement, or allergies. |
| Menu for following week not posted in advance in Garden House dining room. |
| Discontinued medications found in medication cart for resident #1. |
| Expired medication (Calprotect Ointment) found on medication cart. |
| Residents #2 and #3 not educated on right to refuse medication if medication error suspected. |
| Resident #3's initial assessment was completed after the required 15 days post-admission. |
| Resident #3 and #7 assessments missing evaluations for eating, solitary and group activities. |
| Resident support plans for residents #1, #2, #3, and #7 did not document how identified needs will be met. |
| Residents #2 and #6 participated in support plan development but did not sign the plans. |
| Directions for operating key-locking devices not conspicuously posted near door exiting to patio in Secure Dementia Care Unit. |
| Residents #1 and #2 initial support plans were not completed within 72 hours of admission to Secure Dementia Care Unit. |
| Resident #1's record did not include a preadmission screening form. |
Report Facts
License Capacity: 138
Residents Served: 55
Secured Dementia Care Unit Capacity: 19
Residents Served in Secured Dementia Care Unit: 16
Hospice Residents: 3
Residents with Mobility Need: 18
Residents 60 Years or Older: 55
Deficiencies Cited: 28
Inspection Report
Follow-Up
Census: 33
Capacity: 138
Deficiencies: 4
Feb 3, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, with a follow-up type of Plan of Correction (POC) submission.
Findings
The inspection identified multiple deficiencies including mistreatment of a resident by staff, failure to obtain timely criminal background checks, lack of required educational documentation for direct care staff, and missing documentation of completion of Department-approved direct care training. The facility submitted an acceptable plan of correction addressing these issues.
Deficiencies (4)
| Description |
|---|
| A resident was not treated with dignity and respect by staff, including inappropriate verbal responses and placing obstacles in the resident's living space. |
| Criminal background check for staff was not obtained until after the staff was hired. |
| Direct care staff did not have a high school diploma, GED, or active registry status on file. |
| Direct care staff did not have documentation of completion and passing of Department-approved direct care training and competency test. |
Report Facts
License Capacity: 138
Residents Served: 33
Secured Dementia Care Unit Capacity: 19
Residents Served in Dementia Unit: 6
Total Daily Staff: 41
Waking Staff: 31
Residents Diagnosed with Mental Illness: 25
Residents with Mobility Need: 8
Residents with Physical Disability: 2
Residents 60 Years or Older: 33
Inspection Report
Follow-Up
Census: 33
Capacity: 138
Deficiencies: 4
Feb 3, 2022
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction after an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to resident treatment, criminal background checks, and direct care staff qualifications were addressed with corrective actions and training.
Deficiencies (4)
| Description |
|---|
| A resident was not treated with dignity and respect by staff during assistance with showering, causing distress to the resident. |
| Criminal background check for a staff member was not obtained prior to employment. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on file. |
| Direct care staff person did not have documentation of completion and passing of the Department-approved direct care training course and competency test. |
Report Facts
License Capacity: 138
Residents Served: 33
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 6
Residents Diagnosed with Mental Illness: 25
Residents Aged 60 or Older: 33
Residents with Mobility Need: 8
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 33
Capacity: 138
Deficiencies: 20
Oct 13, 2021
Visit Reason
The inspection was conducted as a renewal inspection of THE PINNACLE AT PLYMOUTH MEETING facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including issues with resident contracts, staffing during meal service, first aid/CPR training, emergency telephone postings, first aid kit contents, food storage, emergency preparedness plans, medical evaluations, medication storage and administration, and preadmission screening documentation. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (20)
| Description |
|---|
| Resident-home contract does not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| Insufficient staff to meet residents' meal service needs during lunch on 10/14/2021. |
| No staff present certified in First Aid/CPR during night shifts on 10/04/2021 and 10/07/2021. |
| Trash cans in main kitchen lacked lids on 10/14/2021. |
| Emergency telephone numbers not posted by telephones in resident room #334 and 2nd floor nurse station. |
| First aid kit in 2nd floor nurse station missing antiseptic and adhesive tape. |
| Plastic container with leftover crab cakes opened and unsealed in walk-in freezer. |
| Unlabeled, undated plastic container of frozen haddock in walk-in freezer. |
| Staff person did not have a copy of the emergency preparedness plan for the local municipality. |
| Home's written emergency procedures lacked required elements including emergency medical information plan, emergency contact numbers, and staff duties during evacuation. |
| Home's written emergency procedures not reviewed, updated, or submitted since 09/04/2020. |
| Resident #1 admitted without timely medical evaluation within 60 days prior or 30 days after admission. |
| Medical evaluations for residents #1 and #2 missing required elements such as allergies, special health or dietary needs, medication regimen, and body positioning. |
| Home's menu not posted in Secured Dementia Care Unit. |
| Insulin pens stored at 50°F, exceeding manufacturer recommended temperature range of 36°F to 46°F. |
| Resident #3's prescribed medication not available on 10/14/2021; glucometer readings missing or falsified for residents #3 and #4. |
| Staff person B's medication administration training and diabetes training not current as of inspection date. |
| Preadmission screening forms for residents #1, #2, and #5 missing determinations that resident needs can be met by the home. |
| Medical evaluations for residents #2 and #6 not completed within required timeframe prior to admission to Secure Dementia Care Unit. |
| Resident #6's written cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit. |
Report Facts
Residents served: 33
License capacity: 138
Secured Dementia Care Unit capacity: 19
Residents served in secured dementia care unit: 5
Staffing: 40
Waking staff: 30
Residents with mobility need: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Did not have a copy of the emergency preparedness plan | |
| Staff person B | Med-Aide | Medication administration training and diabetes training not current; observed passing medications during inspection |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 138
Deficiencies: 0
Sep 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 09/13/2021.
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 citations were found, and follow-up was not required.
Report Facts
License Capacity: 138
Residents Served: 30
Secured Dementia Care Unit Capacity: 19
Residents Served in Dementia Unit: 5
Resident Support Staff Hours: 0
Total Daily Staff: 35
Waking Staff: 26
Residents Age 60 or Older: 30
Residents with Mobility Need: 5
Residents with Physical Disability: 5
Notice
Capacity: 138
Deficiencies: 0
Aug 31, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for The Pinnacle at Plymouth Meeting Personal Care Home, following receipt of the renewal application dated July 6, 2021.
Findings
The Department has approved the renewal application and issued a regular license valid from October 8, 2021 to October 8, 2022. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 138
Secure Dementia Care Unit capacity: 19
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: 17
Capacity: 138
Deficiencies: 25
Jun 21, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 06/21/2021 and 06/22/2021.
Findings
Multiple deficiencies were found related to medication administration errors, missing or unsigned resident contracts, incomplete preadmission and cognitive screenings, lack of positive interventions for aggressive behaviors, improper medication storage and labeling, incomplete medication records, and failure to report medication errors. Plans of correction were accepted and implemented with ongoing audits and staff training.
Complaint Details
The inspection was complaint-related with incidents including medication errors, resident fights, and failure to complete required screenings and documentation.
Deficiencies (25)
| Description |
|---|
| Resident #1 did not receive prescribed Tacrolimus medication twice in May because it was not in the home and the incident was not reported to the department. |
| Resident #2 and #3 had unsigned resident-home contracts. |
| Resident #2 and #3 did not have signed statements acknowledging receipt of resident rights and complaint procedures. |
| Residents #2 and #3 engaged in a fight resulting in injuries; no preadmission or cognitive screening was completed and no positive interventions were implemented. |
| Medication errors including incorrect dosages of Lorazepam for Resident #4 and failure to administer prescribed Clearlax for Resident #2. |
| Medications were found not in original labeled containers or unlocked in medication rooms. |
| Discontinued medications were found in the home for Residents #1 and #2. |
| Pharmacy labels for multiple residents' medications did not include prescribed dosage and instructions. |
| OTC medication for Resident #2 was not labeled with the resident's name. |
| Medications for Residents #1, #3, and #4 were not available in the home as prescribed. |
| Glucometer for Resident #5 was not calibrated correctly and blood glucose readings were inaccurately recorded or missing. |
| Narcotic count sheets for Residents #3 and #4 did not match medication inventory. |
| Medication administration records for Residents #1 and #3 were incomplete or not current. |
| Medication administration records for multiple residents lacked staff initials on several dates. |
| Resident #2 was given Clearlax more frequently than prescribed; Resident #4 missed doses of Levemir; Resident #5 missed blood glucose tests; Resident #6 missed administration of Imiquimod cream due to medication unavailability. |
| Medication errors for Resident #1 were not immediately reported to the resident, designated person, or prescriber. |
| No system was in place to identify and document medication errors and patterns of errors. |
| Residents #2 and #3 were not educated on their right to refuse medication if they believed there was an error. |
| Residents #2 and #3 have aggressive behaviors with no positive interventions implemented to modify or eliminate behaviors. |
| Residents #1, #2, and #3 lacked completed preadmission screening forms prior to admission. |
| Resident #1's initial assessment and support plan were not completed within required timeframes. |
| Resident #2's support plan did not document how behavioral needs would be met. |
| Residents #1, #2, and #3 did not sign support plans timely and assessor signatures were missing. |
| Residents #1, #2, and #3 lacked documentation that they or their designated persons did not object to admission to the secured dementia care unit. |
| Resident #3's record did not include the incident report dated 6/17/21. |
Report Facts
Residents served: 17
License capacity: 138
Medication errors: 52
Medication doses missed: 3
Incident date: Jun 17, 2021
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