Deficiencies per Year
28
21
14
7
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 91
Capacity: 106
Deficiencies: 2
Aug 11, 2025
Visit Reason
The inspection visit was a follow-up to review the submitted plan of correction related to prior deficiencies, conducted as a partial, unannounced incident review.
Findings
The report found that the submitted plan of correction was fully implemented. Two specific deficiencies related to incident reporting and abuse were detailed, with corrective actions including staff suspension, training, and ongoing compliance monitoring.
Complaint Details
The visit was complaint-related involving allegations of abuse and failure to report incidents timely. The complaint was substantiated as corrective actions were implemented including suspension and resignation of involved staff.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident in a timely manner as required by regulation 16c. |
| Resident was subjected to physical and verbal abuse by staff, including slapping, shouting, and causing pain with bruising. |
Report Facts
License Capacity: 106
Residents Served: 91
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 5
Residents with Mobility Need: 46
Residents 60 Years or Older: 91
Residents Diagnosed with Intellectual Disability: 1
Residents Diagnosed with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 89
Capacity: 106
Deficiencies: 7
Jul 16, 2025
Visit Reason
The inspection was a partial, unannounced visit triggered by a complaint and incident, conducted to review compliance and investigate specific issues at the facility.
Findings
Multiple deficiencies were identified including lack of required annual training for staff, missing annual medical evaluations for residents, improper storage of medications including expired and discontinued medications, and incomplete resident support plans addressing medical and behavioral needs. Plans of correction were accepted and implemented with ongoing compliance monitoring scheduled.
Complaint Details
The inspection was conducted due to a complaint and incident, with findings substantiating multiple regulatory violations related to training, medical evaluations, medication storage, and resident support plans.
Deficiencies (7)
| Description |
|---|
| Staff Member A did not receive training on meeting the needs of residents as described in preadmission screening, assessment, medical evaluation, and support plan during 2024. |
| Staff Member A did not receive training on emergency preparedness, resident rights, and the Older Adult Protective Services Act during 2024. |
| Resident's most recent medical evaluation was missing or late. |
| Loose white pill found in medication cart; expired eye drops were present beyond manufacturer discard dates. |
| Discontinued medications belonging to a discharged resident were improperly stored in the laundry room. |
| Resident support plan did not document required dietary needs or how they would be met. |
| Resident support plan was not updated to reflect behavioral issues including agitation, aggression, and irritability requiring intervention. |
Report Facts
License Capacity: 106
Residents Served: 89
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 5
Residents Age 60 or Older: 89
Residents with Mobility Need: 46
Total Daily Staff: 135
Waking Staff: 101
Inspection Report
Renewal
Census: 82
Capacity: 106
Deficiencies: 16
Feb 12, 2025
Visit Reason
The inspection was conducted as a licensing inspection including renewal, complaint, provisional, and incident reasons with an unannounced full inspection on February 12 and 13, 2025.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, but multiple deficiencies were cited including contract signatures, staff qualifications, training, emergency procedures, medication management, and record keeping. Plans of correction were accepted and evidence of completion was implemented by April 7, 2025.
Deficiencies (16)
| Description |
|---|
| Resident-home contracts were not signed by the administrator or resident as required. |
| Direct care staff person lacked required high school diploma, GED, or active nurse aide registry status. |
| Staff list did not include agency staff and healthcare director. |
| Insufficient number of staff certified in first aid and CPR during certain shifts. |
| Direct care staff person did not receive required annual training on medication administration, infection control, emergency preparedness, and resident rights. |
| Staff persons did not know the location of the first aid kit. |
| Emergency procedures lacked contact information for residents' designated persons. |
| Resident medical evaluation was not current. |
| Discontinued medication was found in medication cart. |
| Medications were stored improperly with loose pills and punctured blister packs. |
| Pharmacy labels did not match prescriber orders and lacked change of directions stickers. |
| Glucometers were not calibrated correctly and medication availability issues were noted. |
| Medication records lacked required signatures and date/time of administration. |
| Medication was initialed as administered prior to actual administration. |
| No documentation that resident and designated person did not object to admission to secured dementia care unit. |
| Resident narcotic distribution log entries were illegible. |
Report Facts
License Capacity: 106
Residents Served: 82
Secure Dementia Care Unit Capacity: 36
Secure Dementia Care Unit Residents Served: 22
Current Hospice Residents: 5
Total Daily Staff: 104
Waking Staff: 78
Deficiencies Cited: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and report cover letter. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 106
Deficiencies: 24
Dec 9, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit for complaint, incident, and monitoring reasons.
Findings
Multiple deficiencies were identified including breaches in record confidentiality, incomplete resident signed statements, privacy violations, incomplete staff training records, medication storage and administration issues, incomplete medical evaluations and assessments, and improper key-locking device postings. Plans of correction were accepted and many deficiencies were addressed by February 2025.
Complaint Details
The inspection was complaint-related, incident, and monitoring in nature as stated in the inspection information section.
Deficiencies (24)
| Description |
|---|
| Torn tops of medication blister packs containing resident medication information were found unlocked and accessible on a medication cart. |
| Resident record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident privacy was violated when a resident refused to leave another resident's room and staff did not effectively intervene. |
| Direct care staff person provided unsupervised ADL services before completing required training and competency test. |
| Direct care staff person annual training hours could not be determined due to lack of documentation. |
| Direct care staff person did not receive required training in medication self-administration and other key topics during the training year. |
| Direct care staff person did not receive sufficient resident rights training during the training year. |
| Training records did not include length of each course. |
| Food was stored on the floor in the walk-in freezer. |
| Unlabeled, whole fish product stored improperly with bacon wrapped scallops. |
| Initial medical evaluation for a resident was not completed within required timeframe. |
| Annual medical evaluation was incomplete and unsigned by a medical professional. |
| Resident medication record did not include a current list of all medications, including OTC and discontinued medications. |
| Medication blister packs were punctured with pills still in the package. |
| Medications prescribed as needed were not available in the home. |
| Procedures for counting and managing controlled substances were inadequate, with incorrect medication counts and undocumented adjustments. |
| Medication administration training record for a staff person did not include documentation of successful completion. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident’s preadmission screening form was not completed within 30 days prior to admission. |
| Resident initial assessment was not completed within 15 days of admission. |
| Resident annual assessment was not completed timely. |
| Resident support plan did not document medical/dental needs and use of bed rail device. |
| Directions for operating key-locking devices were not conspicuously posted near Secure Dementia Care Unit doors. |
| Records for current and discharged residents were unlocked, unattended, and accessible in the computer room. |
Report Facts
License Capacity: 106
Residents Served: 75
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 2
Total Daily Staff: 124
Waking Staff: 93
Inspection Report
Complaint Investigation
Census: 68
Capacity: 106
Deficiencies: 2
Sep 9, 2024
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to a complaint involving resident safety and care.
Findings
The inspection found that a resident eloped from the secured dementia care unit by entering the posted code on the magnetic door locks and left the facility unsupervised, posing a safety risk. Additionally, a resident's assessment and support plan was not signed by the resident, lacking documentation of participation or refusal.
Complaint Details
The visit was complaint-related due to an incident where a resident eloped from the secured dementia care unit. The resident was returned safely without injury. The complaint was substantiated as the facility failed to prevent elopement and ensure proper documentation of resident support plans.
Deficiencies (2)
| Description |
|---|
| A resident eloped from the secured dementia care unit by entering the posted code on the magnetic door locks and leaving the facility unsupervised. |
| The resident assessment and support plan was not signed by the resident and did not indicate if the resident was unwilling or unable to participate. |
Report Facts
License Capacity: 106
Residents Served: 68
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 18
Total Daily Staff: 117
Waking Staff: 88
Inspection Report
Complaint Investigation
Census: 65
Capacity: 106
Deficiencies: 12
Jul 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/08/2024 and 07/09/2024 to review compliance with submitted plans of correction and regulatory requirements.
Findings
The facility was found to have multiple deficiencies including unsecured resident records, inconsistent assistance with activities of daily living, missing resident contract signatures, lack of signed statements acknowledging resident rights, improper use of restraints, inadequate call bell response times, missing emergency telephone numbers, lack of operable bedside lamps, incomplete medical evaluation documentation, failure to educate residents on the right to refuse medication, and missing no objection statements for secured dementia care unit admissions. All deficiencies had plans of correction accepted and were implemented by 09/20/2024.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason stated as 'Complaint'.
Deficiencies (12)
| Description |
|---|
| Door to the home's Chart Room was propped open leaving approximately 45 resident medical records and a whiteboard with resident information unlocked and accessible to the public. |
| Failure to consistently follow overnight incontinence check schedule for resident #1 as outlined on task sheets. |
| Residency agreement for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident #2 was physically restrained to their bed by a wooden chair and a large pillow with no staff present. |
| Staff do not respond to call bells in a timely manner; multiple call bell response times exceeded the suggested 8 minutes. |
| Resident #3's apartment lacked posted emergency telephone numbers including nearest hospital and fire department. |
| Resident #4 did not have access to an operable bedside lamp; floor lamp was unplugged and cord wrapped around base. |
| Resident #1's medical evaluation included a special diet need not reflected in the resident's support plan; no documentation removing fluid restriction. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #2 was admitted to the Secure Dementia Care Unit without documentation that the resident or designated person objected to the admission; same for resident #4. |
| The home failed to include specific care needs indicated on assignment sheets in resident #1's assessment and support plan. |
Report Facts
Residents Served: 65
License Capacity: 106
Residents Served in Secured Dementia Care Unit: 19
Capacity of Secured Dementia Care Unit: 36
Current Hospice Residents: 9
Residents 60 Years or Older: 64
Residents with Mobility Need: 46
Residents with Physical Disability: 3
Number of Deficiencies: 12
Call Bell Response Times Exceeding 8 Minutes: 7
Inspection Report
Complaint Investigation
Census: 66
Capacity: 106
Deficiencies: 2
Jun 13, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with care requirements, specifically related to wound care and resident treatment.
Findings
The facility failed to provide prescribed wound care to Resident 1 as ordered, including failure to change soiled bandages and follow prescriber’s orders. Staff were not properly trained to provide wound care, and the hospice provider did not follow its treatment plan. Corrective actions and education were implemented following the findings.
Complaint Details
The visit was complaint-related and substantiated by findings that the facility did not provide wound care as prescribed and failed to train staff appropriately. The hospice provider was also not following its treatment plan.
Deficiencies (2)
| Description |
|---|
| Failure to provide prescribed wound care twice a week and as needed, resulting in soiled bandages and untreated wounds. |
| Failure to follow prescriber’s orders for wound care treatment and cleansing. |
Report Facts
License Capacity: 106
Residents Served: 66
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 6
Residents Age 60 or Older: 65
Residents with Mobility Need: 47
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 57
Capacity: 106
Deficiencies: 25
Feb 26, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple deficiencies were identified including medication storage issues, compliance with laws, resident contract and documentation issues, training deficiencies, safety and environmental concerns, and emergency preparedness. Plans of correction were proposed with some implemented and others pending.
Deficiencies (25)
| Description |
|---|
| Medication narcotic count book was unlocked, unattended, and accessible on top of medication cart #2. |
| Carbon Monoxide detector in the kitchen was installed only 10 feet from the gas grill, less than the required 15 feet. |
| Resident contracts were not signed or reviewed timely by residents. |
| Quality management minutes did not include development and implementation of measures to address incidents, complaints, regulatory issues, and resident council minutes. |
| Refunds for deceased residents were not issued within the required timeframe. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff did not receive required annual training on medication self-administration, resident needs, and resident rights. |
| Bedside mobility devices were not properly installed or maintained according to manufacturer instructions. |
| Uncovered trash can in the kitchen. |
| Insufficient hot water in public bathrooms and spa bathroom. |
| First aid kit in the medication room did not include eye coverings. |
| No toilet paper in the second-floor spa bathroom. |
| Outdated or unlabeled food items found in kitchen storage and refrigerator/freezer. |
| Administrator did not have emergency preparedness plan for local municipality. |
| Home's written emergency procedures lacked contact information for residents' designated persons and emergency agencies. |
| Written emergency procedures were not timely submitted to local emergency management agency. |
| Monthly fire drills were planned in advance and held on the same day of the week. |
| Resident self-administered medications were unlocked and unattended in resident's room. |
| Blister packs of medications were damaged or taped, not intact. |
| Medication administration record did not include all prescribed medications. |
| Medication administration training records lacked documentation of successful completion and were not spread out over the year. |
| Resident was not educated on right to refuse medication and documentation was missing. |
| Resident support plans did not include risks, safe use, or identification of bed mobility devices. |
| No written approval for magnetic locking devices on exit doors from Secure Dementia Care Unit. |
| Resident record did not include race or a recent photograph. |
Report Facts
License Capacity: 106
Residents Served: 57
Residents Served in Secure Dementia Care Unit: 15
Total Daily Staff: 97
Waking Staff: 73
Deficiencies Cited: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding issuance of provisional license. |
Inspection Report
Follow-Up
Census: 57
Capacity: 106
Deficiencies: 24
Feb 26, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons, including follow-up on plan of correction submissions.
Findings
Multiple deficiencies were identified including medication storage and administration issues, compliance with laws such as carbon monoxide detector placement, resident contract and record deficiencies, training gaps for staff, fire safety violations, and food safety concerns. Plans of correction were proposed with various completion dates, some implemented and some pending.
Deficiencies (24)
| Description |
|---|
| Medication narcotic count book was unlocked, unattended, and accessible on medication cart. |
| Carbon monoxide detector in kitchen was installed too close (10 feet) to gas grill, violating standards requiring at least 15 feet. |
| Resident contracts were not signed or reviewed timely by residents. |
| Quality management minutes lacked development and implementation of measures addressing incidents, complaints, regulatory issues, and resident council minutes. |
| Refunds for deceased residents were not issued within required timeframes. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff did not receive required annual training on medication self-administration, resident needs, and resident rights. |
| Bedside mobility devices were not used or maintained according to manufacturer instructions and FDA guidelines. |
| Uncovered trash receptacles in kitchen. |
| Insufficient hot water in public bathrooms and spa bathroom. |
| First aid kit in medication room lacked eye coverings. |
| No toilet paper in second-floor spa bathroom. |
| Outdated or unlabeled food items found in kitchen storage and refrigerator/freezer. |
| Administrator did not have emergency preparedness plan for local municipality; emergency procedures lacked required contact information. |
| Written emergency procedures were not timely submitted to local emergency management agency. |
| Monthly fire drills were planned in advance and held on the same day of the week. |
| Resident self-administered medications were unlocked and unsecured in resident rooms. |
| Blister packs of medications were damaged or taped improperly. |
| Medication administration record did not include all prescribed medications. |
| Medication administration training records lacked documentation of successful completion and were not spread over the year. |
| Resident was not educated on right to refuse medication and documentation was missing. |
| Resident support plans lacked documentation on risks, safe use, and identification of bed mobility devices. |
| No written approval for magnetic locking devices on exit doors from Secure Dementia Care Unit. |
| Resident records lacked race and recent photograph. |
Report Facts
License Capacity: 106
Residents Served: 57
Residents Served in Secure Dementia Care Unit: 15
Staffing Hours: 97
Waking Staff: 73
Deficiencies Cited: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter regarding provisional license issuance. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 106
Deficiencies: 1
Dec 14, 2023
Visit Reason
The inspection visit occurred due to a complaint and incident investigation at the facility.
Findings
The submitted plan of correction related to staffing hours during waking hours was reviewed and determined to be fully implemented. The facility initially failed to provide the required 75% of personal care service hours during waking hours, providing only 73%.
Complaint Details
The visit was complaint-related and included an incident. The plan of correction was accepted and fully implemented by 02/05/2024.
Deficiencies (1)
| Description |
|---|
| At least 75% of the personal care service hours specified must be available during waking hours; only 73% were provided. |
Report Facts
Required direct care hours: 92
Provided direct care hours during waking hours: 67.5
License capacity: 106
Residents served: 48
Secured dementia care unit capacity: 36
Residents served in secured dementia care unit: 13
Current hospice residents: 1
Resident mobility needs: 41
Residents with physical disability: 1
Inspection Report
Complaint Investigation
Census: 48
Capacity: 106
Deficiencies: 1
Nov 16, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Findings
The facility was found to have provided only 73% of the required personal care service hours during waking hours, falling short of the 75% requirement. A plan of correction was submitted and accepted, and full compliance was confirmed as of 01/16/2024.
Complaint Details
The inspection was triggered by a complaint and incident, with the plan of correction fully implemented and compliance maintained.
Deficiencies (1)
| Description |
|---|
| Only 58 of the required 79 hours (73%) of personal care service were provided during waking hours, below the required 75%. |
Report Facts
Required direct care hours: 79
Provided direct care hours: 58
Percentage of required hours provided: 73
License capacity: 106
Residents served: 48
Inspection Report
Renewal
Census: 37
Capacity: 106
Deficiencies: 8
Apr 24, 2023
Visit Reason
The inspection was conducted as a renewal visit with provisional and fine reasons, including a full unannounced inspection on 04/24/2023 and 04/25/2023.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected resident abuse, incomplete first aid kits, missing fire extinguisher inspection tags, incomplete fire drill records, medication administration errors, unsigned preadmission cognitive screening, and improperly posted key-locking device instructions. Plans of correction were accepted and implemented by mid-June 2023.
Deficiencies (8)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act. |
| First aid kit in the health and wellness director's office lacked eye coverings, thermometer, gloves, and tweezers. |
| Fire extinguishers in the van and bus were not tagged for inspection by a fire safety expert. |
| Fire drill records did not include exit route used, evacuation time, or time of the fire drill. |
| Medication administration record did not include initials of staff administering medications for Resident 2. |
| Resident 2 and Resident 3 were not administered prescribed medications as ordered. |
| Resident 4's written cognitive preadmission screening was not signed by the assessor. |
| Directions for operating key-locking devices were not conspicuously posted or were incorrect/unreadable at Secure Dementia Care Unit exits. |
Report Facts
Total Daily Staff: 68
Waking Staff: 51
Resident Census: 37
Licensed Capacity: 106
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 12
Residents with Mobility Need: 31
Residents Age 60 or Older: 37
Residents with Physical Disability: 1
Inspection Report
Monitoring
Census: 37
Capacity: 106
Deficiencies: 3
Mar 8, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted for the reasons of a fine and monitoring of the facility's compliance.
Findings
The inspection identified medication administration violations including unqualified individuals administering medications, incorrect medication labeling, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by mid-April 2023.
Deficiencies (3)
| Description |
|---|
| Medications were administered by unqualified individuals not employed by the home. |
| Medication label did not accurately reflect physician's instructions. |
| Failure to administer medication as prescribed on specified days and times. |
Report Facts
License Capacity: 106
Residents Served: 37
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 3
Resident Diagnosed with Mental Illness: 2
Resident Have Mobility Need: 29
Resident Are 60 Years of Age or Older: 36
Resident Have Physical Disability: 1
Inspection Report
Follow-Up
Census: 40
Capacity: 106
Deficiencies: 8
Feb 27, 2023
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a submitted plan of correction after a complaint, incident, and monitoring review.
Findings
The facility was found to have multiple deficiencies related to resident safety and care, including failure to prevent elopement, unsecured poisonous materials, inadequate alarm systems, locked doors impeding egress, improper medication storage, unlabeled medications, and incomplete medical evaluations. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety including elopement and medication management. The complaint was substantiated as deficiencies were found and addressed.
Deficiencies (8)
| Description |
|---|
| Failure to locate Resident #1 promptly in the Secured Dementia Care Unit, with staff not searching a locked showroom room despite police instructions, resulting in a resident elopement risk. |
| Resident #2 was observed unsupervised outside the secured unit; door alarms were not loud enough to alert staff when the television was on. |
| Poisonous materials were found unlocked and accessible to residents in resident rooms without proper assessment of residents' ability to safely use or avoid them. |
| Exit door alarms (screamers) were not loud enough for staff to respond when the TV was on; some exit doors were not working properly. |
| A resident locked themselves in a room with a deadbolt that staff could not open due to lack of key access, impeding egress during a search. |
| An opened bottle of medication in the SDCU was not labeled with an open/discard after date as required. |
| Several bottles of OTC medications in the SDCU medication cart were not labeled with any resident's name. |
| Resident #2 was admitted without a medical evaluation completed within 60 days prior to admission as required. |
Report Facts
Residents served: 40
License capacity: 106
Residents in Secured Dementia Care Unit: 14
Residents aged 60 or older: 39
Residents with mobility needs: 31
Inspection Report
Follow-Up
Census: 37
Capacity: 106
Deficiencies: 1
Jan 26, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction related to an elopement incident involving a Secure Dementia Unit resident was fully implemented. Staff training, elopement drills, resident evaluation, and environmental safety measures were conducted, and a staff member was terminated for failure to respond appropriately.
Deficiencies (1)
| Description |
|---|
| A Secure Dementia Unit resident exited through a stairwell door setting off an alarm while staff failed to respond promptly, endangering the resident. |
Report Facts
License Capacity: 106
Residents Served: 37
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 10
Total Daily Staff: 67
Waking Staff: 50
Residents Age 60 or Older: 35
Residents Diagnosed with Mental Illness: 14
Residents with Mobility Need: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Juno | Vice President of Operations | Named in the letter as recipient and involved in acceptance of plan of correction |
Inspection Report
Follow-Up
Census: 39
Capacity: 106
Deficiencies: 6
Jan 13, 2023
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to medication management and compliance issues.
Findings
The inspection found multiple deficiencies related to medication management including discontinued medications not properly removed, medication storage and availability issues, incomplete medication administration records, and failure to follow prescriber's orders. The facility implemented corrective actions including staff training, medication audits, and process improvements, with all corrections reported as fully implemented by April 2023.
Deficiencies (6)
| Description |
|---|
| Medication discontinued but still present in the home. |
| Expired medication not destroyed according to regulations. |
| Medication prescribed but not available in the home. |
| Medication administration records missing initials of administering staff. |
| Medications not administered according to prescriber's orders. |
| Medications and supplies for self-administration not available in resident's room. |
Report Facts
License Capacity: 106
Residents Served: 39
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 5
Residents with Mobility Need: 30
Residents Age 60 or Older: 37
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 1
Total Daily Staff: 69
Waking Staff: 52
Medication Audits: 2
Inspection Report
Renewal
Census: 37
Capacity: 106
Deficiencies: 8
Nov 21, 2022
Visit Reason
The inspection was conducted as a renewal, provisional, and monitoring visit to assess compliance with licensing regulations for The Landing of Southampton.
Findings
The inspection identified multiple violations including missing influenza awareness postings, unsigned resident contracts, missing telephone number postings, unlocked poisonous materials accessible to residents, furniture and equipment issues, lack of annual fire drill documentation, and medication administration and documentation errors. Some violations were repeat issues from prior inspections.
Deficiencies (8)
| Description |
|---|
| No Influenza poster posted in an area accessible to residents as required by the Influenza Awareness Act. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Telephone numbers for the Department’s personal care home regional office, ombudsman, protective services, and complaint hotline were not posted in a conspicuous and public place. |
| Poisonous materials were unlocked and accessible in a resident's bathroom; not all residents assessed capable of safely using or avoiding poisonous materials. |
| Resident room bed enablers were not covered; cabinet lock in bathroom was broken. |
| Written emergency procedures had not been submitted to the local emergency management agency since January 2020. |
| Fire drill observed by a fire safety expert was not completed in 2021. |
| Medication administration documentation errors including late entries, incorrect medication recorded, and medications not administered as prescribed. |
Report Facts
Census at Inspection: 37
License Capacity: 106
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 5
Calculated Fine: 111
Calculated Fine: 185
Calculated Fine: 185
Inspection Report
Complaint Investigation
Census: 36
Capacity: 106
Deficiencies: 4
Sep 22, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on multiple dates in 2022.
Findings
The facility was found to have multiple violations including failure to report incidents within 24 hours, medication errors involving narcotics accountability and administration of medication to the wrong resident, and failure to follow prescriber's orders. Plans of correction were submitted but some were not implemented by the follow-up dates.
Complaint Details
The inspection was complaint-driven with incidents involving resident falls and medication errors. The complaint was substantiated with multiple violations found.
Deficiencies (4)
| Description |
|---|
| Failure to report seven resident falls to the Department within 24 hours as required. |
| Medication procedures not followed, including miscount of narcotics and improper documentation. |
| Resident administered Alprazolam 0.5 mg prescribed for another resident. |
| Failure to follow prescriber's orders by administering the wrong medication to a resident. |
Report Facts
License Capacity: 106
Residents Served: 36
Census at Inspection: 37
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 111
Calculated Fine Per Day: 185
Number of Falls Not Reported: 7
Inspection Report
Enforcement
Census: 38
Capacity: 106
Deficiencies: 4
Aug 12, 2022
Visit Reason
The inspection was conducted due to an incident at the facility, with a partial, unannounced inspection on 08/12/2022, followed by multiple plan of correction submissions and enforcement actions.
Findings
The facility was found to have violations related to inadequate supervision of a resident who wandered outside the secured unit, resulting in safety risks. The facility failed to provide adequate staffing and supervision as required by the resident's assessment and support plan. The plan of correction was submitted but not implemented by the deadline.
Deficiencies (4)
| Description |
|---|
| Resident #1 exited the secured unit unsupervised and wandered outside due to inadequate supervision and staffing. |
| Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan. |
| Resident #1 was neglected and not properly supervised, resulting in wandering outside the secured unit. |
| Staffing did not meet the needs of residents as specified in the resident’s assessment and support plan. |
Report Facts
Census at Inspection: 37
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 111
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 185
License Capacity: 106
Residents Served: 38
Staffing Hours: 63
Waking Staff: 47
Inspection Report
Enforcement
Census: 39
Capacity: 106
Deficiencies: 7
Aug 1, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit on 08/01/2022 for incident and monitoring reasons, including follow-up on previous deficiencies and enforcement.
Findings
Multiple violations were found related to medication administration errors, late incident reporting, staffing shortages affecting medication delivery, incomplete medical evaluations, and documentation errors. The facility was issued a second provisional license with fines pending if corrections were not made by specified dates.
Deficiencies (7)
| Description |
|---|
| Late reporting of missing medication incidents for Resident #1 and Resident #2. |
| Six residents did not receive their 09:00 PM medications due to lack of available nurse/med-tech trained staff. |
| Resident #3's annual medical evaluation was not completed on time. |
| Medication administration errors including removal of medication from incorrect containers and missed doses. |
| Missing medications could not be accounted for in medication procedures. |
| Medication administration records showed missed or unadministered medications for multiple residents on 07/27/2022. |
| Controlled Substance Logs had illegible entries, overwritten dates and amounts, and scratched out entries without proper notation. |
Report Facts
Census at Inspection: 37
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 111
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 185
License Capacity: 106
Residents Served: 39
Secured Dementia Care Unit Capacity: 36
Residents Served in Dementia Unit: 9
Total Daily Staff: 65
Waking Staff: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed enforcement letter |
Inspection Report
Follow-Up
Census: 41
Capacity: 106
Deficiencies: 2
Mar 2, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have deficiencies related to medication administration records, specifically the lack of exact clock times for medication administration and missing staff initials on medication administration records. The submitted plan of correction was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| The medication administration record (MAR) does not list exact clock times for medication administration, only general time periods such as Early AM, AM, Afternoon, Evening, and PM. |
| The MAR did not include the initials of the staff person who administered the PM dose of medications on 2/20/2022 for a resident. |
Report Facts
License Capacity: 106
Residents Served: 41
Residents in Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 9
Residents 60 Years or Older: 40
Residents Diagnosed with Mental Illness: 17
Residents with Mobility Need: 11
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 38
Capacity: 106
Deficiencies: 9
Feb 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to staff masking, resident care, and incident reporting.
Findings
The inspection found multiple deficiencies including staff not properly wearing masks, delayed response to resident call bells resulting in neglect and injury, incomplete resident contracts, inaccessible support plans, maintenance issues, and failure to report incidents to the department within required timeframes. Plans of correction were accepted and implemented for all deficiencies.
Complaint Details
The complaint investigation was substantiated with findings of staff non-compliance with masking, neglect of residents including delayed call bell responses causing injury, incomplete documentation, and failure to report incidents timely to the department.
Deficiencies (9)
| Description |
|---|
| Staff members were not properly masked, with noses uncovered or no masks worn, increasing COVID-19 transmission risk. |
| Resident #3 did not have a resident-home contract completed within required timeframe. |
| Residents were neglected and intimidated; delayed response to call bells caused injuries and distress. |
| Damaged ceiling tile in hallway appeared water damaged. |
| Broken shower floor partition and drainage issues causing slippery hazards in resident bathrooms; memory care door alarm malfunction. |
| Resident #1's medical evaluations lacked medication and medication regimen documentation. |
| Resident support plans were inaccessible to direct care staff. |
| No objection statements missing for residents admitted to Secure Dementia Care Unit. |
| Failure to report incidents involving residents to the department within 24 hours as required. |
Report Facts
License Capacity: 106
Residents Served: 38
Staffing Hours: 48
Waking Staff: 36
Secured Dementia Care Unit Capacity: 31
Residents in Secured Dementia Care Unit: 9
Hospice Residents: 1
Residents Diagnosed with Mental Illness: 18
Residents Aged 60 or Older: 37
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter regarding plan of correction implementation | |
| Christina Eberhart | Lead inspector on site during inspection dates | |
| General Manager | GM | Named in multiple findings related to staff training, monitoring, and corrective actions |
| Health & Wellness Director | HWD | Involved in monitoring and corrective actions related to deficiencies |
Inspection Report
Monitoring
Census: 31
Capacity: 106
Deficiencies: 5
Dec 20, 2021
Visit Reason
The inspection was a monitoring visit conducted on December 20, 2021, to review compliance with licensing requirements for The Landing of Southampton.
Findings
The inspection identified multiple violations related to criminal background checks, medication management including storage and administration, and adherence to prescriber's orders. A provisional license was issued based on an acceptable plan of correction.
Deficiencies (5)
| Description |
|---|
| Criminal history checks were not completed timely for certain staff members. |
| Prescription medications were not kept in original labeled containers or had compromised blister packs. |
| Discontinued medication was found in the medication room. |
| Medication administration records and narcotic logs lacked required initials and times for administered medications. |
| Medications were administered contrary to prescriber's orders, including administration of discontinued medication and missed doses. |
Report Facts
License Capacity: 106
Residents Served: 31
Staffing Hours: 47
Waking Staff: 35
Secured Dementia Care Unit Capacity: 36
Residents Served in Dementia Unit: 10
Current Hospice Residents: 4
Residents Age 60 or Older: 31
Residents with Mobility Need: 16
Inspection Report
Follow-Up
Census: 40
Capacity: 106
Deficiencies: 10
Nov 17, 2021
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Multiple deficiencies were identified related to contract signatures, medical evaluations, medication administration records, medication administration timing, staff training and competency, following prescriber's orders, and support plan signatures. Plans of correction were accepted and implemented for most deficiencies, with ongoing monitoring by management.
Deficiencies (10)
| Description |
|---|
| Resident-home contract was not signed by the administrator. |
| Resident's medical evaluation did not include special health or dietary needs and health status/cognitive functioning. |
| Resident's medical evaluation was not completed annually as required. |
| Medication administration record (MAR) did not list exact clock times for medication administration. |
| Medication administration times were not consistently recorded at the time of administration. |
| Staff administered insulin injections without completing required Department-approved competency within past 12 months. |
| Medications were not administered as per prescriber's orders; medication was unavailable in the home. |
| Staff administered medications without successfully completing Department-approved medication administration course. |
| Medication administration training records for certain staff were not on file. |
| Support plan signatures were missing from the resident's support plan documentation. |
Report Facts
License Capacity: 106
Residents Served: 40
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 10
Total Daily Staff: 57
Waking Staff: 43
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Notice
Capacity: 106
Deficiencies: 0
Oct 22, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Landing at Southampton 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 a license renewal notice and certificate of compliance.
Report Facts
Total licensed capacity: 106
Secure Dementia Care Unit capacity: 36
Inspection Report
Follow-Up
Census: 45
Capacity: 106
Deficiencies: 4
Oct 14, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 10/14/2021 to review the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included failure to timely report an incident, lack of operable bedside lighting for a resident, incomplete support plan documentation for a high falls risk resident, and missing no objection documentation for admission to the secured dementia care unit. Resident #1 was discharged during the period, affecting some corrective actions.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident involving resident #1 to the Department within 24 hours. |
| Resident #1 did not have access to an operable lamp or other source of lighting at bedside. |
| Resident #1's support plan did not document how the high falls risk need would be met, and recommended safety measures were not in place. |
| No documentation that resident #1 and their designated person did not object to admission to the secured dementia care unit. |
Report Facts
License Capacity: 106
Residents Served: 45
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 12
Total Daily Staff: 65
Waking Staff: 49
Residents with Mobility Need: 20
Residents with Physical Disability: 20
Residents 60 Years or Older: 44
Inspection Report
Complaint Investigation
Census: 42
Capacity: 106
Deficiencies: 22
Sep 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site and off-site visits between September 16 and October 8, 2021, to assess compliance with Pennsylvania Department of Human Services regulations for Personal Care Homes.
Findings
The inspection found multiple violations including denial of immediate access to investigation documentation, failure to report suspected resident abuse, inadequate staff training on abuse recognition and reporting, medication administration errors, improper handling of medications, insufficient staff orientation and training, and deficiencies in resident support plans and documentation.
Complaint Details
The inspection was complaint-driven, with substantiated findings of abuse and neglect, failure to report abuse, and other regulatory violations as detailed in the deficiencies.
Deficiencies (22)
| Description |
|---|
| Denied immediate access to internal investigation documentation regarding abuse. |
| Failure to immediately report suspected sexual assaults involving residents in accordance with the Older Adult Protective Services Act. |
| Failure to notify resident's designated person of a report of suspected abuse. |
| Failure to report incidents of sexual assault to the Department within 24 hours. |
| Resident was witnessed sexually assaulting other residents multiple times; home failed to prevent recurrence. |
| Criminal background checks for some staff were not completed timely or did not comply with all regulatory elements. |
| Staff member was asleep on duty during 1:1 supervision of a resident. |
| Volunteer did not receive required fire safety and emergency preparedness orientation on first day. |
| Direct care staff provided unsupervised ADL services before completing required training and competency test. |
| Sanitary condition violation: dried fruit juice found in kitchen dish in medication cart. |
| Medications in blister packs were taped due to cracking, compromising medication integrity. |
| Discontinued medication found in medication cart and expired medication not removed timely. |
| Medication label and narcotic log inconsistencies regarding dosage instructions. |
| Medication administration records lacked initials and times for multiple medication administrations. |
| Failure to report resident refusal of medication to prescriber within 24 hours. |
| Failure to follow prescriber's orders; medications not administered or unavailable on multiple occasions. |
| Use of chemical restraint (Lorazepam) to control resident behavior without proper indication. |
| Resident and assessor did not sign and date support plan. |
| Medical evaluation for resident in secured dementia care unit did not indicate need for secured care. |
| Written cognitive preadmission screening for residents in secured dementia care unit was completed after admission. |
| Support plans failed to identify or address residents' supervision needs, behaviors, and medical conditions. |
| Resident record did not include an incident report as required. |
Report Facts
Inspection dates: 7
License capacity: 106
Residents served: 42
Staff on duty: 58
Waking staff: 44
Residents in secured dementia care unit: 12
Hospice residents: 5
Residents 60 years or older: 40
Residents with mobility needs: 16
Residents with physical disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to failure to report abuse, medication errors, and chemical restraint use. | |
| Staff member B | Named in findings related to delayed criminal background check. | |
| Staff member C | Named in findings related to delayed criminal background check and lack of fire safety orientation. | |
| Staff member D | Named in finding related to sleeping on duty during 1:1 supervision. | |
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the provisional license letter. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 106
Deficiencies: 2
Jul 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review concerns related to staffing and sanitary conditions at the facility.
Findings
The facility was found to be understaffed on the day of inspection, resulting in delayed breakfast service and cancellation of a scheduled activity. Additionally, sanitary conditions were compromised due to improper disposal of soiled personal care products by family members.
Complaint Details
The visit was complaint-related as stated under Inspection Reason: Complaint. No substantiation status is explicitly stated.
Deficiencies (2)
| Description |
|---|
| The home served breakfast late due to only having one server for PC and memory care, and the scheduled 10:00 am activity was not held due to being understaffed. |
| Soiled personal products were not being disposed of properly in the appropriate trash receptacles; family members were assisting with trash removal and disposing of contaminated waste outside the home. |
Report Facts
License Capacity: 106
Residents Served: 39
Residents Served in Secured Dementia Care Unit: 11
Current Hospice Residents: 5
Total Daily Staff: 42
Waking Staff: 32
Resident Support Staff: 0
Residents 60 Years or Older: 38
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 39
Capacity: 106
Deficiencies: 10
Jul 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/16/2021 and 08/03/2021 to review compliance and follow-up on a plan of correction submission.
Findings
Multiple deficiencies were identified including failure to report an incident, unlocked resident records in a secure medication room, inadequate staffing to meet resident needs, missing criminal background checks for staff, medication unavailability, incomplete preadmission screenings, lack of documentation of resident consent for secured dementia care unit admission, and failure to revise support plans after resident condition changes.
Complaint Details
The inspection was complaint-driven, with a focus on verifying compliance with submitted plans of correction. The complaint involved multiple issues including resident safety, staffing, and documentation.
Deficiencies (10)
| Description |
|---|
| Failure to submit an incident report to the Department after resident had an unwitnessed fall with injuries. |
| Resident records were unlocked, unattended, and accessible in the secure dementia unit medication room. |
| Resident found in cold room with inadequate clothing and uncovered legs; staff unable to attend due to workload. |
| Two staff members hired without criminal background checks on file. |
| Inadequate staffing in the secured dementia care unit to meet resident transfer and ADL needs. |
| Direct care staff person provided unsupervised ADL services without completing required training and competency test. |
| Medication (Senna Plus .50mg Tab) was not available in the home as prescribed. |
| Written cognitive preadmission screening was not completed for a resident admitted to the secured dementia care unit. |
| No documentation that resident and designated person did not object to admission to the secured dementia care unit. |
| Support plan was not revised to address frequent falls and condition changes for a resident. |
Report Facts
License Capacity: 106
Residents Served: 39
Residents in Secured Dementia Care Unit: 11
Current Hospice Residents: 5
Total Daily Staff: 50
Waking Staff: 38
Residents 60 Years or Older: 38
Residents with Mobility Need: 11
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 28
Capacity: 106
Deficiencies: 5
Feb 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 02/25/2021.
Findings
The inspection identified multiple deficiencies including failure to submit incident reports, incomplete medical evaluations after condition changes, delayed initial resident assessments, missing significant change support plans, and unsigned support plans. The facility submitted a plan of correction which was determined to be fully implemented by the follow-up.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was accepted and fully implemented as of the follow-up review.
Deficiencies (5)
| Description |
|---|
| Failure to submit an incident report to the Department after resident hospitalization for bleeding, edema, and increased confusion. |
| Failure to complete a status change medical evaluation (DME) after resident's condition changed prior to annual evaluation. |
| Resident's initial assessment was not completed within 15 days of admission. |
| Failure to complete a Significant Change Support Plan after resident's condition significantly changed. |
| Support plan was not signed or dated by the resident or the home. |
Report Facts
License Capacity: 106
Residents Served: 28
Secured Dementia Care Unit Capacity: 36
Residents Served in Dementia Unit: 5
Hospice Residents: 2
Residents Age 60 or Older: 27
Residents with Mental Illness: 1
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Notice
Capacity: 106
Deficiencies: 0
Jan 20, 2021
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for The Landing of Southampton Personal Care Home, confirming the facility's authorized capacity and advising of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Maximum licensed capacity: 106
Secure Dementia Care Unit capacity: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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