Inspection Reports for The Remington of Yardley
255 Oxford Valley Rd, Yardley, PA 19067, United States, PA, 19067
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Inspection Report
Renewal
Census: 101
Capacity: 115
Deficiencies: 10
Apr 7, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of required annual and dementia-specific staff training, sanitary condition issues such as urine odor and medication handling violations, inoperable lighting, improper food storage, lint accumulation in dryers, obstructed egress routes, medication administration and documentation errors, and incomplete resident mobility assessments. Plans of correction were accepted and implemented with follow-up audits and education scheduled.
Complaint Details
The inspection included a complaint investigation component, but no substantiation status was explicitly stated in the report.
Deficiencies (10)
| Description |
|---|
| Staff person A did not receive required annual training in resident rights, Older Adult Protective Services Act, and falls/accident prevention during the 2024 training year. |
| Staff persons A and B did not receive required dementia-specific training within required timeframes. |
| Strong odor of urine and stain detected on recliner in Resident 1’s room; medication administered without gloves by Staff person C. |
| Resident 2 did not have access to an operable lamp or source of lighting at bedside. |
| Opened and unsealed food items found in main kitchen walk-in freezer. |
| Approximately 1/2 inch thickness of lint observed in lint traps of dryers in first-floor laundry room. |
| Trash cart obstructing Exit Tower Stairwell #1, blocking egress path and limiting accessibility. |
| Resident 3 refused medication doses on three dates; refusals were not reported to prescriber within 24 hours. |
| Medications for Residents 4 and 5 were not administered as prescribed on specified dates. |
| Resident assessments and support plans did not indicate need for bedside mobility devices present in four residents’ rooms. |
Report Facts
License Capacity: 115
Residents Served: 101
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 19
Hospice Residents: 2
Total Daily Staff: 120
Waking Staff: 90
Residents 60 Years or Older: 101
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to lack of annual training, dementia-specific training, and medication administration. | |
| Staff person B | Named in findings related to dementia-specific training. | |
| Staff person C | Named in medication administration violation for not wearing gloves. |
Inspection Report
Follow-Up
Census: 105
Capacity: 115
Deficiencies: 3
Mar 11, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have implemented the submitted plan of correction related to medication storage, medication procedures, and following prescriber's orders. Several deficiencies were identified during the prior inspection, including punctured medication blister packs, lack of procedures to investigate missing medications, and medication administration errors, all of which have been addressed with training, audits, and policy updates.
Deficiencies (3)
| Description |
|---|
| Medication blister packs were punctured and taped over, compromising medication integrity. |
| Procedures did not include a process to investigate and account for missing medications and medication errors. |
| Medication was administered at an incorrect time not ordered by the prescriber. |
Report Facts
License Capacity: 115
Residents Served: 105
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 20
Current Hospice Residents: 3
Total Daily Staff: 125
Waking Staff: 94
Missing Narcotic Pills: 1
Inspection Report
Complaint Investigation
Census: 101
Capacity: 115
Deficiencies: 1
Sep 10, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident reported at the facility.
Findings
The inspection found a deficiency related to incomplete documentation in a resident's medical evaluation form, specifically lacking details on body positioning and movement stimulation despite indicating it was applicable. The submitted plan of correction was accepted and fully implemented by December 4, 2024.
Complaint Details
The visit was complaint-related with the reason stated as 'Complaint, Incident'. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Medical evaluation form for a resident indicated 'Yes' for body positioning/movement stimulation but did not describe the details or resident's need. |
Report Facts
License Capacity: 115
Residents Served: 101
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 21
Hospice Current Residents: 5
Residents with Mobility Need: 28
Residents Age 60 or Older: 101
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 3
Mar 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on reviewing the submitted plan of correction.
Findings
The facility was found to have deficiencies related to dementia-specific training not provided within 30 days of hire, failure to follow prescriber’s medication orders for multiple residents, and staff administering medications without documented completion of a Department-approved medication administration course. The submitted plans of correction were accepted and determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Staff Person A did not receive required dementia-specific training within 30 days of hire. |
| Residents did not receive prescribed medications as ordered, including missed doses due to medication unavailability. |
| Staff persons A and B administered medications without documented completion of required medication administration course. |
Report Facts
License Capacity: 115
Residents Served: 103
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 21
Hospice Residents: 5
Residents with Mobility Need: 30
Staffing Hours - Total Daily Staff: 133
Staffing Hours - Waking Staff: 100
Inspection Report
Follow-Up
Census: 106
Capacity: 115
Deficiencies: 3
Mar 4, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to fire drill procedures, designated meeting place evacuation, and self-administered medication records. Deficiencies involved incomplete fire drill evacuation accounting and missing CAM and OTC medications in resident records, all of which were addressed with updated procedures and staff education.
Deficiencies (3)
| Description |
|---|
| Fire drill record indicated 94 residents evacuated but one resident did not evacuate and was found unconscious. |
| Residents did not evacuate to a designated meeting place during fire drills; instead, they waited at doorways for staff instructions. |
| Resident's medication record did not include CAM and OTC medications found in the resident's living unit. |
Report Facts
License Capacity: 115
Residents Served: 106
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 21
Residents with Mobility Need: 31
Residents 60 Years or Older: 106
Staffing Hours - Total Daily Staff: 137
Staffing Hours - Waking Staff: 103
Residents Present at Fire Drill: 94
Residents Evacuated at Fire Drill: 94
Inspection Report
Renewal
Census: 100
Capacity: 115
Deficiencies: 11
Feb 5, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Heartis Yardley facility to review compliance and the submitted plan of correction.
Findings
Multiple deficiencies were identified including incomplete staff training on fire safety and abuse reporting, unsecured bedside mobility devices, missing emergency telephone numbers, lack of operable bedside lamps, improper food storage, lint accumulation in dryer, medication management issues, and incomplete resident support plan reviews. Plans of correction were accepted and implemented by early April 2024.
Deficiencies (11)
| Description |
|---|
| Staff person A did not receive orientation on fire safety topics including evacuation procedures, staff duties during fire drills, designated meeting place, and smoking safety procedures. |
| Staff person A did not complete training on resident rights and mandatory reporting of abuse and neglect within 40 scheduled working hours. |
| Staff persons A and B did not attend annual 2023 training in fire safety, emergency preparedness, resident rights, OAPSA, and falls and accident prevention. |
| Bedside mobility devices on residents #1, #2, and #3 beds were not securely attached to the bed frame. |
| Emergency telephone numbers including nearest hospital and fire department were missing on or by the telephones in residents #2 and #4 bedrooms. |
| Residents #2 and #5 did not have access to a source of light that can be turned on/off at bedside. |
| Ice cream in the ice cream freezer was opened and unsealed. |
| Approximately 1/4-inch accumulation of lint was found in the lint trap of the dryer in the laundry room on the 1st floor. |
| Discontinued medication for resident 1 was found in the medication cart. |
| Resident 1 was prescribed medication that was not administered because it was not available in the residence. |
| Resident 6's support plan had not been reviewed on a quarterly basis; last review date was missing. |
Report Facts
License Capacity: 115
Residents Served: 100
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents Age 60 or Older: 100
Residents with Mobility Need: 39
Total Daily Staff: 139
Waking Staff: 104
Inspection Report
Complaint Investigation
Census: 103
Capacity: 115
Deficiencies: 9
Jan 8, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/08/2024 and 01/09/2024.
Findings
The inspection found multiple deficiencies including failure to issue timely refunds, inadequate staffing and supervision in the secured dementia care unit, malfunctioning door locks, incomplete annual medical evaluations, sanitary practice violations, unsecured medications, and improper discharge/transfer procedures without required notices or physician certifications.
Complaint Details
The inspection was complaint-driven and incident-related. The complaint involved issues such as improper discharge procedures, inadequate staffing, and safety concerns in the secured dementia care unit. The report indicates follow-up and plan of correction submissions were required and implemented.
Deficiencies (9)
| Description |
|---|
| Failure to issue refund to resident within required timeframe after discharge. |
| Inadequate staffing and supervision in the Secured Dementia Care Unit (SDCU), with doors propped open and no staff physically present. |
| Magnetic locking system on SDCU doors malfunctioned allowing resident to force open door; main entrance door did not lock properly. |
| Residents did not have annual medical evaluations completed as required. |
| Staff observed working in kitchen without hair net, violating sanitary practices. |
| Medications and syringes were kept unsecured in unlocked dresser drawer and kitchen cupboard. |
| Discharge notices did not include required explanation of resident rights and ombudsman contact information. |
| Resident discharged without 30-day advance written notice and without physician certification that delay would jeopardize health or safety. |
| Resident discharged on grounds of being a danger without written certification from physician or Department. |
Report Facts
Total Daily Staff: 143
Waking Staff: 107
License Capacity: 115
Residents Served: 103
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 20
Residents with Mobility Need: 40
Deficiency Plan of Correction Completion Dates: Feb 29, 2024
Inspection Report
Complaint Investigation
Census: 102
Capacity: 115
Deficiencies: 5
Nov 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 11/06/2023.
Findings
The inspection identified multiple deficiencies including sanitary conditions with malodorous smells in a resident's room, incomplete first aid kit supplies, improper food storage, and issues with resident support plans including outdated assessments and missing signatures. All deficiencies had plans of correction submitted and were implemented by 02/26/2024.
Complaint Details
The inspection was triggered by a complaint, and the exit conference was held on 11/27/2023. The submitted plan of correction was fully implemented as of 02/26/2024.
Deficiencies (5)
| Description |
|---|
| Malodorous smell of incontinence concerns in a resident's room indicating unsanitary conditions. |
| First aid kit in the special care unit did not include goggles. |
| Applesauce on the medication cart in the special care unit was opened and unsealed. |
| Resident support plan assessment was outdated and did not reflect current resident needs. |
| Resident support plan was not signed and dated by the resident as required. |
Report Facts
License Capacity: 115
Residents Served: 102
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 20
Total Daily Staff: 145
Waking Staff: 109
Residents Age 60 or Older: 103
Residents with Mobility Need: 43
Inspection Report
Follow-Up
Census: 107
Capacity: 115
Deficiencies: 3
Sep 13, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to abuse/neglect and medical evaluation were addressed with corrective actions completed by the specified dates.
Deficiencies (3)
| Description |
|---|
| Resident 1 reported disappearance of money from their bedside table drawer, indicating possible unauthorized search and missing funds. |
| Resident 2 reported missing approximately $200 to $250 from their room, with details on stored money and timing of discovery. |
| Medical evaluations for Resident 1 did not include tuberculosis testing; this section of the form was blank. |
Report Facts
Residents served: 107
License capacity: 115
Residents in special care unit: 21
Current hospice residents: 5
Residents age 60 or older: 107
Residents with mobility need: 46
Inspection Report
Complaint Investigation
Census: 105
Capacity: 115
Deficiencies: 15
Jul 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident care and facility compliance.
Findings
The inspection found multiple violations including exceeding licensed capacity in the Special Care Unit, incidents of abuse/neglect, failure to provide requested safety accommodations, improper resident rights restrictions, inadequate staffing hours, incomplete medical evaluations, medication storage issues, and deficiencies in resident support plans and documentation.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason explicitly stated as 'Complaint'.
Deficiencies (15)
| Description |
|---|
| Exceeded licensed capacity in Special Care Unit with 22 residents present versus licensed capacity of 21. |
| Unsafe handling of Resident 2 by staff leading to fall and head injury. |
| Neglected installation of requested grab bar resulting in Resident 3's fall and neck fracture. |
| Resident 1 denied right to leave and return without proper diagnosis or support plan documentation. |
| Insufficient direct care staffing hours provided for mobile residents on 6/25/23. |
| Shower area in living unit lacked required grab bars, hand rails, or assist bars causing resident injury. |
| Medical evaluation for Resident 2 missing immunization history. |
| Medication prescribed to Resident 1 was not available in the residence on inspection day. |
| Resident 1 lacked access to keypad codes to exit Special Care Unit despite not having dementia diagnosis. |
| Resident 1's support plan lacked assessment for eating, drinking, toileting, transferring, and ambulating. |
| Resident 2's assessment did not include ambulating needs despite requiring a rollator walker. |
| Resident 3's support plan was unsigned by assessor. |
| Resident 1's medical evaluation lacked diagnosis of dementia and need for Special Care Unit placement. |
| Resident 1's cognitive preadmission screening lacked dementia or Alzheimer's diagnosis. |
| Resident 1 admitted to Special Care Unit without spouse or family member with dementia diagnosis. |
Report Facts
Residents served: 105
License capacity: 115
Special Care Unit capacity: 21
Special Care Unit residents: 22
Direct care staffing hours required: 127
Direct care staffing hours provided: 123
Grab bars in shower area: 3
Inspection Report
Complaint Investigation
Census: 97
Capacity: 115
Deficiencies: 4
May 1, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to complaint, incident, and monitoring reasons, with exit conference on 05/02/2023.
Findings
The inspection found multiple deficiencies related to resident care including inadequate assistance with IADLs, medication management errors such as outdated medications in the cart, incorrect medication administration records, and failure to document medication administration times properly. Plans of correction were accepted and later implemented.
Complaint Details
The inspection was complaint-related, triggered by complaints, incidents, and monitoring. Specific substantiation status is not stated.
Deficiencies (4)
| Description |
|---|
| Resident #1 did not receive laundry assistance as required and was unaware of a scheduled appointment due to staff communication failures. |
| Resident #2 had a medication (Mucus Relief tab 30-600 ER) in the medication cart that was not an active order. |
| Resident #1's medication record for Bupropion was inaccurate, showing incorrect dosage frequency. |
| Medication administration times were not properly recorded, including a discrepancy with Lorazepam administration documentation. |
Report Facts
License Capacity: 115
Residents Served: 97
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 16
Resident Mobility Need: 21
Total Daily Staff: 118
Waking Staff: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN | LPN responsible for medication administration error and re-educated on 5/18/2023. | |
| RCD/GPD or designee | Responsible for conducting audits, re-education, and ensuring compliance with medication and resident care plans. | |
| Nurse Consultant | Provided nursing support and conducted LPN re-education. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 115
Deficiencies: 7
Mar 14, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation, including unannounced partial inspections on 03/14/2023 and 03/15/2023, and an off-site review on 03/16/2023, to assess compliance with regulatory requirements and the submitted plan of correction.
Findings
The inspection found multiple deficiencies including abuse/neglect involving physical restraint causing injury, dignity and respect violations related to delayed call bell responses, insufficient waking staff hours, inadequate staffing in the secured care unit, lack of licensed nurse coverage on a specific date, broken furniture posing hazards, and prohibited restraint practices. Plans of correction were accepted and partially implemented.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse/neglect and other incidents. The complaint was substantiated based on findings of physical restraint causing injury and other violations.
Deficiencies (7)
| Description |
|---|
| Resident #1 was physically restrained by staff resulting in small cuts and bruises, constituting abuse/neglect. |
| Resident #2 experienced long wait times for call bell response and was subjected to racial slurs by staff. |
| Only 65.21% of required personal care service hours were provided during waking hours on a specified Sunday. |
| Staffing in the secured care unit was insufficient to meet the needs of residents requiring two-person assistance. |
| No licensed nurse was available in the building or on call on Sunday 02/26/23 from 6:00 AM to 10:00 PM. |
| Furniture in resident #2's apartment was broken and hazardous, requiring replacement. |
| Staff physically restrained resident #1 and pushed them to a seated position in a chair, violating prohibitions on restraints. |
Report Facts
Residents served: 93
License capacity: 115
Residents served in Special Care Unit: 17
Current Hospice Residents: 4
Residents with mobility needs: 17
Residents aged 60 or older: 93
Residents diagnosed with mental illness: 1
Direct care hours required on Sunday: 110
Direct care hours provided during waking hours: 71.74
Percentage of required waking hours provided: 65.21
Shifts worked on date in question: 22
Shifts during waking hours: 17
Hours worked during waking hours: 125
Inspection Report
Renewal
Census: 97
Capacity: 115
Deficiencies: 20
Feb 13, 2023
Visit Reason
The inspection was conducted as a renewal inspection with additional complaint and incident reasons, including an unannounced full inspection on February 13 and 14, 2023.
Findings
The facility was found to have multiple deficiencies including incomplete medical evaluations, unsigned contracts, abuse/neglect incidents, missing criminal background checks, incomplete staff training, fire safety issues, medication administration errors, and missing signatures on support plans. Plans of correction were accepted and many were implemented by May 2023.
Deficiencies (20)
| Description |
|---|
| Resident #1's medical evaluation was not completed within required time frames. |
| Resident #2's contract was not signed by the resident. |
| Resident #3 reported missing money, indicating possible abuse/neglect by staff. |
| Staff person A's criminal background check did not include a PA PATCH clearance. |
| Staff person A did not receive required fire safety orientation on first day. |
| Staff person A did not complete required 40-hour rights/abuse training within scheduled hours. |
| Dementia training record missing for staff person C. |
| Trash cans in kitchen and bathrooms lacked proper covers. |
| First aid kit in secured dementia care unit missing scissors, tweezers, and thermometer. |
| Resident room #7 lacked an operable lamp or source of light at bedside. |
| Food stored in uncovered containers in kitchen refrigerator. |
| Administrator did not have a copy of the emergency preparedness plan for the local municipality. |
| Written emergency procedures not submitted annually to local emergency management agency since 2021. |
| Fire drill during sleeping hours not conducted within required timeframe. |
| Medication administration errors involving discontinued Lorazepam PRN blister pack. |
| Discontinued medication Lorazepam PRN still present in medication cart. |
| Medication Diphenoxylate/Atropine not available in residence as prescribed. |
| Medication administration record missing initials of staff administering Clonazepam PRN. |
| Resident #7's support plan was not signed or dated by assessor or resident. |
| Resident #1 and #7 cognitive preadmission screening forms were incomplete or late. |
Report Facts
License Capacity: 115
Residents Served: 97
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 19
Hospice Residents: 6
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Renewal
Census: 97
Capacity: 115
Deficiencies: 20
Feb 13, 2023
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons on 02/13/2023 and 02/14/2023.
Findings
The inspection identified multiple deficiencies including issues with medical evaluations, contract signatures, abuse/neglect allegations, criminal background checks, fire safety orientation, staff training, medication administration errors, emergency preparedness, and documentation of support plans. Plans of correction were accepted and many were implemented by May 2023.
Deficiencies (20)
| Description |
|---|
| Resident #1's medical evaluation was not completed within required time frames. |
| The contract for resident #2 was not signed by the resident. |
| Resident #3 reported $40 missing from wallet; staff persons involved were removed and abuse training provided. |
| Staff person A's criminal background check did not include a PA PATCH clearance. |
| Staff person A did not receive required fire safety orientation on first day of work. |
| Staff person A did not complete required 40-hour orientation training including resident rights and abuse reporting. |
| Dementia training record missing for staff person C. |
| Trash cans in activity room and bathroom lacked proper covers. |
| First aid kit in secured dementia care unit missing scissors, tweezers, and thermometer. |
| Resident room #7 lacked an operable lamp or source of lighting at bedside. |
| Food stored in uncovered containers in kitchen refrigerator. |
| Staff person D did not have a copy of the emergency preparedness plan for the local municipality. |
| Written emergency procedures not submitted annually to local emergency management agency since 2021. |
| Fire drill during sleeping hours not conducted within required timeframe. |
| Resident #4's medication administration failed to follow proper procedures; discontinued PRN medication remained in medication cart and was administered. |
| Discontinued medication for resident #4 was found in medication cart. |
| Resident #5's prescribed medication was not available in the residence. |
| Resident #6's medication administration record lacked initials of administering staff on one occasion. |
| Resident #7's initial assessment/support plan was not signed or dated by assessor or resident. |
| Resident #1 and #7's cognitive preadmission screening forms were incomplete or missing required information. |
Report Facts
License Capacity: 115
Residents Served: 97
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 19
Current Hospice Residents: 6
Number of Deficiencies: 20
Inspection Report
Complaint Investigation
Census: 94
Capacity: 115
Deficiencies: 8
Dec 7, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple off-site review dates between 12/07/2022 and 12/19/2022.
Findings
The facility was found to have multiple deficiencies including failure to provide assistance with ADLs, abuse/neglect issues, inadequate staffing and support plans, insufficient first aid/CPR trained staff, lack of fire safety orientation for new staff, incomplete rights/abuse training, incomplete direct care training, and failure to complete required cognitive preadmission screening for a resident. Plans of correction were accepted and implemented by 05/17/2023.
Complaint Details
The inspection was complaint-related with substantiation implied by the findings of neglect and abuse/neglect violations.
Deficiencies (8)
| Description |
|---|
| Failure to provide resident #1 with assistance with toileting and bladder and bowel management as required by the resident's assessment and support plan. |
| Resident #1 was neglected when staff did not check on them during the night shift and only one staff was scheduled to work in the Special Care Unit despite the need for two. |
| Inadequate staffing to meet the needs of residents as specified in their assessment and support plans, including overnight shifts with insufficient staff. |
| Insufficient number of staff trained and certified in first aid and CPR present at all times to meet resident needs. |
| New direct care staff did not receive required fire safety orientation on their first day of work. |
| Direct care staff person did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, abuse and neglect reporting, and core competencies. |
| Direct care staff person did not complete the Department-approved direct care training course and competency test. |
| Resident #1's written cognitive preadmission screening was not completed within 72 hours prior to admission to the special care unit. |
Report Facts
License Capacity: 115
Residents Served: 94
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 18
Current Hospice Residents: 4
Residents Age 60 or Older: 94
Residents with Mental Illness: 2
Residents with Mobility Need: 20
Staff Resident Support: 125
Total Daily Staff: 239
Waking Staff: 179
Staff to Resident Ratio for First Aid/CPR: 1
Inspection Report
Monitoring
Census: 93
Capacity: 115
Deficiencies: 12
Nov 28, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted on 11/28/2022 and 11/29/2022 for incident and monitoring purposes, including a follow-up on plan of correction submissions.
Findings
The facility was found to have multiple deficiencies including incomplete resident contracts, failure to treat residents with dignity and respect, missing FBI clearance for a staff member, direct care staff providing unsupervised services without required training, unlocked poisonous materials accessible to residents, medication labeling and administration errors, incomplete resident assessments and support plans, and inadequate documentation for special care unit admissions. Plans of correction were accepted or directed with completion dates mostly by early 2023 and were reported as implemented by 04/04/2023.
Deficiencies (12)
| Description |
|---|
| Resident-residence contract did not include a list of assisted living services or actual rates based on support plan for resident #1. |
| Staff member pushed resident #2's wheelchair into a table and did not address the resident's complaint. |
| Failed to obtain FBI clearance for a staff member without Pennsylvania residency for the last 2 years. |
| Direct care staff person B provided unsupervised assisted living services without completing 18 hours of required training. |
| Toothpaste and bar of soap labeled as poisonous were unlocked and accessible to residents not assessed as safe to use them. |
| Medication blister pack for resident #5 did not reflect physician's changed order. |
| Medication administration record for resident #2 missing staff initials for administration of Oxycodone and Tramadol on specified dates. |
| Resident #3's assessment did not include assistance given for toileting after significant condition change. |
| Resident #1's medical evaluation did not include the need for special care unit placement. |
| Resident #1's cognitive preadmission screening was not dated and stated no need for special care unit services. |
| Resident #1's initial support plan was not completed upon admission to the special care unit. |
| Resident #1's support plan did not address multiple witnessed and unwitnessed falls or prevention strategies. |
Report Facts
License Capacity: 115
Residents Served: 93
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 18
Hospice Residents: 2
Total Daily Staff: 118
Waking Staff: 89
Number of Falls: 12
Inspection Report
Monitoring
Census: 56
Capacity: 115
Deficiencies: 5
Apr 27, 2022
Visit Reason
The inspection was a monitoring visit conducted as an Interim Plan of Correction (POC) inspection to review compliance and progress on previously identified violations.
Findings
Multiple deficiencies were found including missing eye coverings in the first aid kit, staff misconduct involving identity fraud, incomplete staff orientation and training on fire safety, resident rights, abuse reporting, and dementia-specific training. Plans of correction were accepted but some were noted as not implemented at the time of the report.
Deficiencies (5)
| Description |
|---|
| The first aid kit located in the Wellness Office does not include eye coverings. |
| Direct care staff copied resident's identity documents and texted them to friends with intent to commit identity fraud. |
| Staff person A did not receive orientation on general fire safety and emergency preparedness on first day of work. |
| Staff persons A and B did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, abuse reporting, reportable incidents, safe management techniques, and core competency training. |
| Staff persons A and C did not complete dementia-specific training within 30 days of hire. |
Report Facts
License Capacity: 115
Residents Served: 56
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 11
Hospice Residents: 2
Resident Support Staff: 87
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to identity fraud, fire safety orientation, rights/abuse training, and dementia training deficiencies | |
| Staff member B | Named in findings related to identity fraud and rights/abuse training deficiencies | |
| Staff member C | Named in findings related to dementia training deficiency | |
| Staff member D | Reported identity fraud incident to administration and was placed on suspension during investigation |
Inspection Report
Follow-Up
Census: 60
Capacity: 115
Deficiencies: 6
Apr 25, 2022
Visit Reason
The inspection visit on April 25, 2022 was conducted as a follow-up to address violations found during a previous licensing inspection related to the Assisted Living Residence regulations.
Findings
The inspection identified multiple violations including failure to treat residents with dignity and respect, unsafe access to poisonous materials, incomplete medical evaluations, missing initial assessments, incomplete preliminary support plans, and resident records lacking incident reports. Directed plans of correction with specified completion dates were issued for all deficiencies.
Deficiencies (6)
| Description |
|---|
| Resident was not treated with dignity and respect; staff threatened resident during an argument. |
| Poisonous materials were accessible to a resident not evaluated as safe around poisons. |
| Medical evaluation for a resident did not include the date the evaluation was completed. |
| Resident's initial assessment was not completed within 30 days prior to admission. |
| Resident's written preliminary support plan was not completed within 30 days prior to admission. |
| Resident records did not include copies of incident reports for multiple residents. |
Report Facts
License Capacity: 115
Residents Served: 60
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 11
Hospice Residents: 2
Resident Mobility Need: 17
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Renewal
Census: 55
Capacity: 115
Deficiencies: 27
Feb 16, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to report resident abuse, lack of proper staff qualifications and training, missing emergency telephone numbers, incomplete resident assessments and support plans, and issues with medication management and safety protocols. Plans of correction were submitted and accepted for all deficiencies with implementation dates provided.
Deficiencies (27)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report an incident to the Department’s assisted living residence office within 24 hours. |
| Lack of carbon monoxide alarm in the home with gas fired hot water heaters. |
| Resident admitted without a signed resident-residence contract. |
| Resident call bell response times were excessively long, with some responses over 40 minutes. |
| Direct care staff did not have criminal background checks at time of hire. |
| Direct care staff lacked required qualifications such as high school diploma or GED. |
| Direct care staff did not receive orientation in general fire safety and emergency preparedness on first day. |
| Direct care staff did not complete required orientation training on Resident Rights, Emergency Medical Plan, Reporting of Incidents, and Safe Management Techniques within 40 hours. |
| Direct care staff provided unsupervised assisted living services prior to completion of Department approved training and competency test. |
| Direct care staff did not complete 18 hours of required initial direct care training. |
| Direct care staff did not complete required dementia-specific training within 30 days of hire. |
| Poisonous materials (toothpaste) were stored unlocked in resident room accessible to residents. |
| Emergency telephone numbers were not posted on or by the telephone in resident room 116. |
| First aid kit in Wellness Center lacked scissors and band aides. |
| Lint accumulation in lint trap of commercial dryer. |
| Written emergency procedures did not include measures for residents not connected to emergency generator during power outage. |
| Medical evaluation for resident missing date of physician completion. |
| Expired medication was present on medication cart available for administration. |
| Resident's initial assessment was not completed within 30 days prior to admission. |
| Resident's written initial assessment did not include use of oxygen. |
| Resident's written preliminary support plan was not completed within 30 days of admission. |
| Licensed staff did not sign and date the preliminary support plan. |
| Resident's additional written assessment was not completed after significant change in condition. |
| Resident did not sign and date the support plan. |
| Resident's record did not include a copy of the resident-home contract. |
Report Facts
Residents Served: 55
License Capacity: 115
Staffing Hours - Resident Support Staff: 101
Staffing Hours - Total Daily Staff: 187
Staffing Hours - Waking Staff: 140
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 9
Current Hospice Residents: 2
Residents Age 60 or Older: 53
Residents with Mobility Need: 31
Residents with Physical Disability: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in multiple findings related to abuse reporting, staff supervision, training, and medical evaluation oversight | |
| Memory Care Director | Named in findings related to abuse reporting, staff supervision, training, and dementia care | |
| Business Office Director | Named in findings related to staff background checks, qualifications, and documentation oversight | |
| Executive Director | Named in findings related to staff education, plan of correction oversight, and emergency procedures | |
| Staff person A | Involved in resident abuse allegation | |
| Staff person B | Named in findings related to criminal background check, qualifications, orientation, and training deficiencies | |
| Staff person C | Named in findings related to criminal background check, qualifications, orientation, training, and dementia training deficiencies | |
| Staff person D | Named in findings related to orientation and training deficiencies | |
| Staff person E | Named in findings related to orientation, training, and dementia training deficiencies |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 115
Deficiencies: 17
Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation following reports of multiple issues including a power outage affecting resident rooms, delayed staff response times, and other regulatory concerns.
Findings
The facility experienced a power outage affecting 29 resident rooms with no heat, electricity, or interconnected smoke detectors, resulting in resident discomfort and safety risks. Multiple deficiencies were found including inadequate emergency preparedness, staffing issues, delayed response to call bells, incomplete resident support plans, and missing documentation of resident signatures on support plans.
Complaint Details
The inspection was complaint-driven due to issues including a power outage affecting resident safety and comfort, delayed staff responses, and concerns about emergency preparedness and resident care.
Deficiencies (17)
| Description |
|---|
| Residents were without electricity, heat, and interconnected smoke detectors during a power outage; no fire watch was conducted. |
| Delayed staff response to resident call bells, with some responses taking over 60 minutes. |
| The home was without a qualified administrator from 9/15/21 to 10/26/21. |
| Inadequate housekeeping services reported by residents. |
| Indoor temperature in resident rooms was below required minimum during power outage. |
| Smoke detectors in 29 resident rooms were not interconnected to the fire alarm monitoring station. |
| Emergency preparedness plan was not fully implemented; failure to notify local emergency agencies during power outage. |
| Emergency procedures did not include how to meet needs of 50% of residents during utility outage. |
| Emergency procedures had not been submitted annually to the local emergency management agency. |
| Emergency evacuation diagram lacked line of travel notation. |
| Condiments were not available at the dining table during a meal. |
| Additional portions of meals were not available at mealtime. |
| Weekly menus were not posted in a conspicuous and public place. |
| Resident assessment did not include plan to support COPD and oxygen usage. |
| Directions for operating key-locking devices were not conspicuously posted near certain doors. |
| Resident was not treated with dignity and respect; delayed response to call bell during utility outage. |
| Residents participated in support plan development but did not sign or date the plans; no notation of refusal was made. |
Report Facts
Residents present: 47
Licensed capacity: 115
Rooms without power: 29
Staff response time: 65
Staff response time: 29
Staff response time: 17
Staff response time: 30
Staff response time: 36
Housekeeping staff: 2
Inspection Report
Complaint Investigation
Census: 47
Capacity: 115
Deficiencies: 15
Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation following multiple inspection dates in late 2021 to assess violations related to assisted living residence regulations.
Findings
The inspection found multiple violations including neglect during a power outage affecting 29 residents without heat or electricity, delayed staff response times to call bells, lack of qualified administrator for a period, inadequate housekeeping services, missing condiments at meals, incomplete emergency procedures, and deficiencies in resident support plans and documentation.
Complaint Details
The inspection was complaint-driven, triggered by concerns about resident neglect and safety during a power outage and other issues. The complaint was substantiated based on findings of neglect, delayed staff response, and inadequate emergency preparedness.
Deficiencies (15)
| Description |
|---|
| Residents on the 2nd floor experienced a power outage with no heat, electricity, or fire watch; delayed staff response to call bells; oxygen concentrator issues. |
| The home was without a qualified administrator from 9/15/21 to 10/26/21. |
| Inadequate housekeeping services reported by residents. |
| Indoor temperature was below required levels during power outage; no blankets initially provided. |
| Smoke detectors on 2nd floor were not interconnected to fire monitoring station. |
| Condiments were not available at the dining tables during a meal. |
| Emergency procedures did not address meeting needs of 50% of residents during utility outage. |
| Written emergency procedures had not been submitted to local emergency management agency as required. |
| Emergency evacuation diagram lacked line of travel near elevator on first floor. |
| Emergency procedures did not specify actions when smoke detectors or fire alarms are inoperable. |
| Weekly menus were not posted in a conspicuous and public place. |
| Resident #1’s assessment did not include plan for oxygen usage and medical needs. |
| Directions for operating key-locking devices were not conspicuously posted near certain doors. |
| Resident #4 reported staff did not check on them during utility outage despite needing assistance; delayed call bell response times. |
| Residents #1, #2, and #3 participated in support plan development but did not sign or date plans; no notation of refusal was documented. |
Report Facts
Residents present during inspection: 47
Total licensed capacity: 115
Staffing: 74
Waking staff: 56
Residents without electricity during outage: 29
Call bell response times: 65
Call bell response times: 29
Call bell response times: 17
Call bell response times: 30
Call bell response times: 36
Housekeeping staff: 2
Inspection Report
Complaint Investigation
Census: 31
Capacity: 115
Deficiencies: 21
Sep 9, 2021
Visit Reason
The inspection was a complaint investigation conducted as a partial, unannounced review of the Heartis Yardley assisted living facility to assess compliance with regulations and investigate specific complaints.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, missing resident contract signatures, lack of signed statements acknowledging resident rights, abuse and neglect concerns, inadequate staff qualifications and training, incomplete medical evaluations, and deficiencies in resident support plans and discharge notices. Several plans of correction were proposed but not fully implemented as of the report date.
Complaint Details
The inspection was conducted as a complaint investigation with multiple allegations including failure to report incidents, abuse/neglect, inadequate staff qualifications and training, and deficiencies in resident care and documentation. The complaint was substantiated with numerous violations found.
Deficiencies (21)
| Description |
|---|
| Failure to report incidents to the Department within required timeframes. |
| Resident contracts for two residents were not signed by the residents. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Resident #5 eloped multiple times and the facility failed to update support plans or provide adequate supervision. |
| Resident #1 violated home rules by bringing prohibited items and engaging in disruptive behavior. |
| Staff recorded resident without consent violating privacy rights. |
| Criminal background checks missing for two staff members. |
| Direct care staff member lacked required high school diploma, GED, or nurse aide registry status. |
| Substitute staff lacked documented orientation on fire safety and resident rights within required timeframes. |
| Staff member did not complete required dementia-specific training within 30 days of hire. |
| Medical evaluations for several residents lacked documentation of TB skin test or chest x-ray. |
| Residents #4 and #5 were not educated on their right to refuse medication. |
| Failure to employ safe management techniques to prevent and deescalate resident altercations. |
| Preliminary support plans for residents were not reviewed or approved by an RN. |
| Preliminary support plans lacked signatures from residents or designated persons. |
| Final support plan for resident #4 was not completed within 30 days of admission. |
| Resident support plans did not document behavioral issues or updated medical orders. |
| Resident support plans were not signed by assessors or residents, and refusals to sign were not documented. |
| Resident discharge notices lacked required information including reason, effective date, location, appeal rights, and ombudsman contact. |
| Resident #5's medical evaluation for special care unit admission was incomplete or outdated. |
| Written cognitive preadmission screenings for special care unit admissions were incomplete or missing. |
Report Facts
License Capacity: 115
Residents Served: 31
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 7
Total Daily Staff: 56
Waking Staff: 42
Inspection Report
Monitoring
Census: 27
Capacity: 115
Deficiencies: 4
Jul 8, 2021
Visit Reason
The inspection was a monitoring visit conducted on 07/08/2021 to review the facility's compliance with regulatory requirements and the implementation of a previously submitted plan of correction.
Findings
The inspection found deficiencies related to staff training on mandatory reporting of abuse and neglect, resident education on the right to refuse medication, and documentation/signatures on support plans. The facility submitted plans of correction which were accepted and implemented.
Deficiencies (4)
| Description |
|---|
| Staff person did not complete required training on mandatory reporting of abuse and neglect, reporting of reportable incidents and conditions, and safe management techniques within 40 scheduled work hours. |
| Resident #1 and Resident #2 were not educated on their right to refuse medication if they believed there was a medication error, and no signed documentation was provided. |
| Resident #1 and Resident #2 participated in the development of support plans but did not sign and date the support plans. |
| No notation was made regarding Resident #1 and Resident #2's refusal or inability to sign the support plans. |
Report Facts
Total Daily Staff: 49
Waking Staff: 37
License Capacity: 115
Residents Served: 27
Special Care Unit Capacity: 21
Special Care Unit Residents Served: 7
Hospice Residents: 1
Residents Diagnosed with Mental Illness: 16
Residents Aged 60 or Older: 27
Residents with Mobility Need: 22
Residents with Physical Disability: 3
Inspection Report
Original Licensing
Capacity: 115
Deficiencies: 2
Mar 1, 2021
Visit Reason
The inspection was conducted as an initial licensing inspection of the newly licensed assisted living facility, Heartis Yardley, which was not yet serving four or more residents at the time.
Findings
The facility was found to be in substantial compliance with applicable regulations but the inspection was incomplete due to the low census. Citations were issued related to trash receptacles and hot water temperature, which were corrected with plans of correction submitted and implemented.
Deficiencies (2)
| Description |
|---|
| Trash outside the home was not kept in covered receptacles, with dumpster lid open and three outdoor trash cans without lids or coverings. |
| Hot water temperature in room 101 measured 122.5°F, exceeding the maximum allowed 120°F. |
Report Facts
License Capacity: 115
Special Care Unit Capacity: 21
Residents Served: 0
Hot water temperature: 122.5
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