Inspection Reports for The Residence at Presque Isle Bay
1012 W Bayfront Pkwy Erie, PA 16507, United States, PA
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Inspection Report
Renewal
Census: 66
Capacity: 138
Deficiencies: 0
May 21, 2025
Visit Reason
The inspection was conducted as part of a renewal process, with additional consideration for complaint and provisional reasons, as indicated in the inspection information.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted on 05/21/2025 and 05/22/2025.
Report Facts
Total Daily Staff: 86
Waking Staff: 65
License Capacity: 138
Residents Served: 66
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 3
Residents 60 Years of Age or Older: 66
Residents with Mobility Need: 20
Inspection Report
Follow-Up
Census: 63
Capacity: 138
Deficiencies: 2
Feb 28, 2025
Visit Reason
The inspection visit on 02/28/2025 was conducted as a partial, unannounced review due to a complaint and incident.
Findings
The facility was found to have deficiencies related to annual medical evaluations and additional resident assessments following behavioral changes. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Complaint Details
The visit was complaint-related, triggered by reports of resident behavioral changes including yelling, foul language, punching staff, and throwing dining ware. The complaint was substantiated by staff interviews indicating these behaviors were not documented in resident assessments.
Deficiencies (2)
| Description |
|---|
| Resident did not have medical evaluations completed at least annually, with a previous evaluation dated 6/28/23 and a delayed follow-up completed on 8/16/24. |
| Resident assessments did not reflect significant behavioral changes such as yelling, using foul language, punching staff, and throwing dining ware over the past 2-3 months. |
Report Facts
License Capacity: 138
Residents Served: 63
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 3
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 23
Inspection Report
Complaint Investigation
Census: 62
Capacity: 138
Deficiencies: 2
Jan 27, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE RESIDENCE AT PRESQUE ISLE BAY.
Findings
The facility was found to have neglected a resident by failing to administer prescribed medication, resulting in the resident being found unresponsive and later dying. The facility violated regulations regarding abuse and following prescriber's orders, with repeat violations noted.
Complaint Details
The visit was complaint-related, investigating neglect and failure to administer prescribed medication. The complaint was substantiated as the resident was found unresponsive and later died due to acute respiratory failure linked to the neglect.
Deficiencies (2)
| Description |
|---|
| Failure to administer prescribed medication to a resident, resulting in neglect and subsequent resident death. |
| Failure to follow the directions of the prescriber regarding medication administration. |
Report Facts
Residents Served: 62
License Capacity: 138
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 3
Waking Staff: 62
Total Daily Staff: 83
Residents Age 60 or Older: 62
Residents with Mobility Need: 21
Inspection Report
Follow-Up
Census: 62
Capacity: 138
Deficiencies: 1
Aug 12, 2024
Visit Reason
The inspection visit was conducted as a follow-up to a complaint and incident, with a partial unannounced inspection on site to verify the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with corrective actions taken to ensure resident support plans accurately document medical and behavioral care needs. Continued compliance must be maintained.
Complaint Details
The visit was complaint-related, triggered by a complaint and incident. The plan of correction was accepted and fully implemented as of 10/22/2024.
Deficiencies (1)
| Description |
|---|
| The resident's support plan did not document how medical needs related to Depression, Kidney Disease, Neuropathy, and Hypertension would be met. |
Report Facts
License Capacity: 138
Residents Served: 62
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 30
Residents with Mobility Need: 25
Residents Age 60 or Older: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Took immediate action to correct the support plan and conducted monthly audits | |
| Executive Operations Officer | Conducted training on the importance of matching medical documents |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 138
Deficiencies: 3
Jun 28, 2024
Visit Reason
The inspection was an unannounced partial inspection conducted due to complaint, incident, and fine reasons.
Findings
The inspection identified multiple deficiencies including evidence of bed bug infestation, incomplete annual medical evaluations for residents, and missing cognitive preadmission screenings for residents admitted to the secured dementia care unit. Plans of correction were submitted and accepted with follow-up dates scheduled.
Complaint Details
The inspection was triggered by complaints and incidents related to infestation and compliance with medical and preadmission screening requirements.
Severity Breakdown
S: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Evidence of infestation of approximately 200 bed bugs found between the mattresses of resident #1’s bed, with resident showing multiple bite marks and reddened areas. | S |
| Resident #2’s most recent medical evaluation was not current as required; annual medical evaluations were incomplete. | — |
| Written cognitive preadmission screening was not completed for residents #2 and #3 prior to admission to the secured dementia care unit. | — |
Report Facts
Residents Served: 56
License Capacity: 138
Bed Bugs Found: 200
Residents Diagnosed with Mental Illness: 15
Residents Age 60 or Older: 56
Residents with Mobility Need: 25
Residents in Secured Dementia Care Unit: 15
Secured Dementia Care Unit Capacity: 22
Current Hospice Residents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Associate | Assisted with showering resident #1 to remove bed bugs and clean wounds | |
| Safety and Maintenance Engineer | Removed and disposed of bedding and mattress; coordinated pest control treatment and monitoring | |
| Resident Wellness Director | Conducted audit of medical evaluations, completed cognitive preadmission screenings, and implemented tracking and training | |
| Nathan Maietta | Executive Operations Officer | Provided training and implemented move-in audit for secured dementia care unit admissions |
Inspection Report
Census: 46
Capacity: 138
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 138
Residents Served: 46
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Resident Support Staff: 0
Total Daily Staff: 64
Waking Staff: 48
Residents Age 60 or Older: 45
Residents with Mobility Need: 18
Inspection Report
Follow-Up
Census: 53
Capacity: 138
Deficiencies: 5
May 1, 2024
Visit Reason
The inspection visit was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including failure to report an incident, resident abuse and neglect, failure to secure medical care, failure to conduct additional assessments after significant resident changes, and failure to revise support plans timely.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident involving a resident found with a laundry bag string around the neck to the Department within 24 hours. |
| Resident abuse and neglect including failure to assess and implement adequate services after multiple falls and injuries. |
| Failure to assist resident in securing required medical care and follow-up appointments after hospital discharge. |
| Failure to conduct additional assessments after significant changes in resident condition prior to annual assessment. |
| Failure to revise the support plan within 30 days upon completion of the annual assessment or upon changes in resident needs. |
Report Facts
License Capacity: 138
Residents Served: 53
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 16
Hospice Residents: 3
Total Daily Staff: 72
Waking Staff: 54
Residents 60 Years or Older: 51
Residents with Mobility Need: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Associate | Named in relation to immediate actions taken for incident documentation and removal of laundry bag. | |
| Resident Wellness Director | Named in relation to corrective and preventative actions including reporting incidents, updating care plans, scheduling follow-ups, and reassessments. | |
| Executive Operations Officer | Named in relation to training wellness team members and removal of string bagged laundry bags. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 138
Deficiencies: 0
Apr 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation at THE RESIDENCE AT PRESQUE ISLE BAY.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, and no deficiencies were found. Substantiation status is not explicitly stated.
Report Facts
License Capacity: 138
Residents Served: 48
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 2
Resident Support Staff: 0
Total Daily Staff: 66
Waking Staff: 50
Residents Age 60 or Older: 47
Residents with Mobility Need: 18
Inspection Report
Enforcement
Census: 48
Capacity: 138
Deficiencies: 20
Feb 13, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, incident, and interim review purposes.
Findings
Multiple violations were found including failure to timely report incidents, inadequate supervision leading to resident falls, abuse reporting deficiencies, medication administration errors, inadequate staffing, unsafe environmental conditions, and incomplete resident records. The facility was issued a first provisional license due to these violations and a plan of correction was required.
Complaint Details
The inspection included complaint investigation related to abuse reporting delays, financial mismanagement, resident falls, and treatment of residents. Some violations were repeat from prior inspections. The complaint was substantiated based on findings.
Deficiencies (20)
| Description |
|---|
| Failure to immediately report suspected abuse incidents to the Department and Area Agency on Aging. |
| Resident #1 experienced multiple falls with injuries; facility failed to provide adequate supervision. |
| Resident #3 and #4 found in inappropriate and unsafe conditions in secured dementia care unit. |
| Staff person used resident's prepaid debit card without authorization; financial mismanagement. |
| Hot water temperature exceeded 120°F in common bathrooms. |
| Windows and screens were damaged or missing in multiple locations. |
| Residents lacked operable bedside lamps or lighting sources. |
| Food storage violations including unsealed and undated food items. |
| Fire drill records incomplete or not documented in military time. |
| Resident medical evaluations not current or missing required documentation. |
| Medication records missing diagnosis information and failure to report medication refusals. |
| Failure to follow prescriber's orders for blood glucose monitoring and insulin administration. |
| Resident assessments incomplete or not updated to reflect significant changes. |
| Resident cognitive preadmission screening not completed within required timeframe. |
| Resident record entries obscured by correction fluid, making signatures illegible. |
| Poisonous materials accessible to residents without proper locking. |
| Staff person lacked current criminal background check upon promotion. |
| No staff trained in first aid and CPR present during certain shifts. |
| Resident altercation resulting in physical contact without injury. |
| Residents not always treated with dignity and respect; behavioral issues not fully addressed. |
Report Facts
License Capacity: 138
Residents Served: 48
Secured Dementia Care Unit Capacity: 22
Residents Served in SDCU: 12
Staffing Hours: 65
Waking Staff: 49
Fine Amounts: 672
Correction Dates: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
| Staff person F | Admitted to unauthorized use of resident prepaid debit card; charged by police. | |
| Staff person A | Administrative Services Director / Executive Operations Officer | Promoted without updated background check; involved in reporting violations. |
| Resident Wellness Director | Responsible for implementing corrective actions, training, and monitoring resident care. | |
| Safety and Maintenance Engineer | Responsible for environmental corrections including water temperature and window screens. | |
| Executive Operations Officer | Oversight of quality management plan and enforcement follow-up. | |
| Administrative Services Director | Responsible for auditing financial records and training. |
Inspection Report
Enforcement
Census: 48
Capacity: 138
Deficiencies: 16
Feb 13, 2024
Visit Reason
The inspection was conducted as a full renewal inspection combined with complaint, incident, and interim reviews to assess compliance with regulatory requirements.
Findings
The facility was found to have multiple violations including failure to timely report incidents, inadequate supervision leading to resident falls, financial record discrepancies, medication administration issues, and environmental safety concerns. Several repeat violations were noted. The facility was issued a first provisional license with fines pending correction of violations.
Deficiencies (16)
| Description |
|---|
| Failure to immediately report suspected abuse incidents to the local Area Agency on Aging and Department. |
| Resident abuse incidents involving inappropriate resident interactions and staff misuse of resident funds. |
| Inadequate staffing levels to meet residents' mobility and evacuation needs during night shifts. |
| Hot water temperature exceeded 120°F in common bathrooms. |
| Damaged window screens and missing screens in resident rooms and common areas. |
| Residents lacking operable bedside lamps or lighting sources. |
| Failure to properly store and label food items in kitchen areas. |
| Fire drill records lacked military time and AM/PM designation. |
| Residents did not have annual medical evaluations up to date. |
| Medication storage and equipment calibration issues, including uncalibrated glucometer. |
| Medication administration records missing diagnosis indications for several medications. |
| Failure to document and report resident medication refusals to prescribers. |
| Failure to follow prescriber's orders for blood glucose monitoring and insulin administration. |
| Initial and additional resident assessments missing or incomplete, not reflecting current diagnoses or behavioral changes. |
| Resident preadmission cognitive screening not completed within required timeframe. |
| Resident record entries were obscured by correction fluid, making signatures illegible. |
Report Facts
License Capacity: 138
Residents Served: 48
Staffing Hours: 65
Waking Staff: 49
Fines: 672
Correction Dates: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
| Unnamed Executive Operations Officer | Executive Operations Officer | Named in multiple findings related to quality management, incident reporting, and corrective actions. |
| Unnamed Resident Wellness Director | Resident Wellness Director | Named in findings related to resident care, abuse reporting, assessments, and staff training. |
| Unnamed Safety and Maintenance Engineer | Safety and Maintenance Engineer | Named in findings related to environmental safety, hot water temperature, and maintenance. |
| Unnamed Administrative Services Director | Administrative Services Director | Named in findings related to financial record keeping and staff background checks. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 138
Deficiencies: 4
Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 01/24/2024 and 01/25/2024, followed by an off-site exit conference on 03/04/2024.
Findings
The inspection found multiple deficiencies including improper treatment of a resident causing pain and fear, an unsigned medical evaluation, failure to reassess a resident after a significant health event, and lack of posted access code for secured unit exit devices. Corrective actions included staff termination, new medical director contract, training sessions, and posting of access codes.
Complaint Details
The inspection was complaint-driven, investigating allegations of resident abuse and neglect. The complaint was substantiated with findings including staff abuse and failure to properly evaluate resident medical and dietary needs.
Deficiencies (4)
| Description |
|---|
| Staff member grabbed resident's arm causing significant pain and fear, violating dignity and respect requirements. |
| Resident's most recent medical evaluation was not signed by a medical professional. |
| Resident was not evaluated for appropriate diet consistency after choking incident despite observed risk. |
| No access code posted at main exit/entrance of secured dementia care unit. |
Report Facts
License Capacity: 138
Residents Served: 53
Residents in Secured Dementia Care Unit: 14
Staffing Hours - Total Daily Staff: 81
Staffing Hours - Waking Staff: 61
Resident Meals Not Eaten: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Named in finding related to resident abuse involving grabbing resident's arm. | |
| Executive Operations Officer | Involved in investigation, reporting, corrective actions, and training related to deficiencies. | |
| Resident Wellness Director | Involved in investigation, corrective actions, training, and implementation of new procedures. | |
| Safety and Maintenance Engineer | Responsible for posting access code at secured dementia care unit exit. |
Inspection Report
Plan of Correction
Census: 52
Capacity: 138
Deficiencies: 1
Jun 15, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The inspection found staffing deficiencies on the secured dementia unit where two staff members were occupied with one resident's care, leaving other residents unsupervised. The facility submitted a plan of correction which was accepted and later implemented.
Deficiencies (1)
| Description |
|---|
| Insufficient staffing on the secured dementia unit during the morning shift, resulting in 15 residents being left unsupervised while two staff assisted one resident requiring two-person care. |
Report Facts
License Capacity: 138
Residents Served: 52
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 1
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Renewal
Census: 49
Capacity: 138
Deficiencies: 17
May 24, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including unannounced full inspections on 5/24/23, 5/25/23, and 5/31/23, to assess compliance with licensing regulations and investigate incidents.
Findings
The inspection identified multiple deficiencies including failure to fully implement the plan of correction, resident abuse reporting delays, inadequate staffing during emergency evacuations, environmental hazards, fire safety violations, medication storage discrepancies, and lack of sufficient activities in the secured dementia care unit (SDCU). Several corrective actions were directed or accepted with specified completion dates.
Deficiencies (17)
| Description |
|---|
| Failure to immediately report suspected abuse of residents in the secured dementia care unit. |
| Failure to report incidents to the Department’s personal care home complaint hotline within 24 hours. |
| Failure to provide adequate supervision to prevent resident-to-resident incidents in the SDCU. |
| Inadequate staffing to meet residents' evacuation needs during overnight shifts. |
| Floors, walls, ceilings, windows, doors and other surfaces not in good repair or free of hazards (e.g., unsecured wooden molding, missing light cover). |
| Hot water temperature exceeded 120°F in resident-accessible areas. |
| Furniture and equipment not in good repair (e.g., broken shut off valve, broken water regulator, damaged swivel chair). |
| Resident did not have access to an operable lamp or source of lighting at bedside. |
| Food requiring refrigeration not stored at or below 40°F; freezer temperatures above required levels. |
| Lint accumulation in dryer vent ducts creating fire hazard. |
| Fire drill records incomplete or missing required information (e.g., exit routes, time of day). |
| Fire drills not conducted during sleeping hours as required. |
| Fire drills not held on varied days/times and documentation included non-participating staff. |
| Residents not evacuated to designated meeting places during fire drills; inadequate evacuation of SDCU residents. |
| Menus not posted weekly in a conspicuous place. |
| Discrepancy in narcotic medication count for a resident. |
| Lack of sufficient activities offered weekly in the secured dementia care unit. |
Report Facts
License Capacity: 138
Residents Served: 49
Residents with Mobility Needs: 25
Staffing: 74
Waking Staff: 56
Hot Water Temperature: 138.5
Hot Water Temperature: 140.5
Fire Drill Duration: 8.04
Fire Drill Duration: 7.14
Medication Count Discrepancy: 1
Inspection Report
Monitoring
Census: 47
Capacity: 138
Deficiencies: 8
Feb 14, 2023
Visit Reason
The inspection was a monitoring visit conducted on 02/14/2023 to review the facility's compliance with previously submitted plans of correction.
Findings
The inspection identified multiple deficiencies including unsecured electronic medical records, unsanitary conditions in the kitchen freezer, unsecured handrails, damaged window screens, lack of bedside lighting for a resident, missing monthly fire drills, incomplete fire drill records, and a missing medical evaluation for a resident. Plans of correction were submitted and partially implemented with some evidence of completion noted.
Deficiencies (8)
| Description |
|---|
| Homes electronic medical records laptop was unlocked, unsecured, and unattended on the secure dementia unit medication cart. |
| Wall and floor of the ice cream freezer in the main kitchen was covered with sticky substances. |
| Handrail on the wall across from the 1st floor common bathroom was not secured and moved approximately ½ inch, exposing sharp edges. |
| Third window in the home's Bistro area had no screen; first window had a screen not securely attached with a 1" separation. |
| Resident #2 did not have access to a source of light that could be turned on/off at bedside. |
| An unannounced fire drill was not held during November 2022 and December 2022. |
| Fire drill record for the drill conducted on 8/1/22 did not include the exit route used. |
| Resident #3 did not have a medical evaluation documented on a form specified by the Department within required timeframe. |
Report Facts
License Capacity: 138
Residents Served: 47
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 5
Residents Age 60 or Older: 47
Residents with Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 43
Capacity: 138
Deficiencies: 1
Dec 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with licensing requirements at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. A deficiency was found regarding a resident-home contract missing for Resident #1 after ownership change in March 2022, which was later corrected.
Complaint Details
The visit was complaint-related and the plan of correction submitted was accepted and fully implemented as of the inspection date.
Deficiencies (1)
| Description |
|---|
| Resident #1 does not have a resident-home contract with the new owner after ownership change in March 2022. |
Report Facts
License Capacity: 138
Residents Served: 43
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Residents Age 60 or Older: 43
Residents with Mental Illness: 1
Residents with Mobility Need: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Named in plan of correction audit and contract process | |
| Community Relations Director | Named in plan of correction audit and contract process |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 138
Deficiencies: 4
Sep 27, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 09/27/22, 09/30/22, and 10/07/22.
Findings
The facility was found to have deficiencies related to inadequate supervision leading to resident abuse, incomplete medical evaluations missing critical information, and failure to document diagnoses necessary for secured dementia care unit placement. Plans of correction were submitted but not fully implemented as of the follow-up dates.
Complaint Details
The visit was complaint-related, investigating an incident where resident #1 inappropriately touched resident #2 multiple times, causing distress. The facility was aware of resident #1's behavior but failed to provide adequate supervision. The complaint was substantiated based on the findings.
Deficiencies (4)
| Description |
|---|
| Inadequate supervision leading to resident #1 engaging in inappropriate sexual behavior and abuse of resident #2. |
| Resident #3's initial medical evaluation lacked height, weight, and pulse rate documentation. |
| Resident #4's initial medical evaluation did not indicate special health or dietary needs nor cognitive functioning; medical diagnoses section referenced attachments that were missing. |
| Resident #4's medical evaluation did not document diagnosis of Alzheimer's disease or other dementia or the need for secured dementia care unit placement. |
Report Facts
License Capacity: 138
Residents Served: 38
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 14
Hospice Residents: 4
Staffing Hours - Total Daily Staff: 61
Staffing Hours - Waking Staff: 46
Residents with Mobility Need: 23
Residents 60 Years or Older: 38
Inspection Report
Renewal
Census: 40
Capacity: 138
Deficiencies: 20
Jul 26, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons, with an exit conference held on 2022-08-02.
Findings
The inspection identified multiple deficiencies including unsecured resident records, staff sleeping on duty, unsanitary refrigerator conditions, maintenance issues such as broken handrails and torn window screens, medication labeling errors, incomplete medical evaluations and assessments, missing preadmission screening forms, and incomplete support plans. Plans of correction were submitted but not fully implemented as of the last follow-up.
Deficiencies (20)
| Description |
|---|
| Resident #1's interdisciplinary progress notes were unsecured and accessible in a common area. |
| Staff members were found asleep during shifts when 40 residents were present. |
| Sticky substances found inside refrigerators and freezer areas. |
| Handrail in common bathroom was pulled away from the wall exposing sharp edges. |
| Torn window screen in the 1st floor bistro. |
| Magnetic locking mechanism on door from secure dementia care unit to courtyard was inoperable. |
| Resident #1 did not have access to operable bedside lighting. |
| Lint accumulation in lint trap of industrial dryer. |
| Resident #2's miniature poodle lacked current rabies vaccination certificate on file. |
| Fire drill records lacked number of residents evacuated and exit routes used. |
| Medical evaluations for residents #3 and #4 were not completed timely and lacked required information. |
| Menus were not posted weekly as required. |
| Resident #4's medication lacked pharmacy label. |
| Resident #1's medication was administered more frequently than prescribed. |
| Missing preadmission screening forms for residents #3 and #4. |
| Initial assessments for residents #3 and #4 were not completed within 15 days of admission. |
| Resident #1's assessment did not address increased needs and behavioral changes; resident #6's assessment did not indicate need for Hoyer lift. |
| Initial support plans for residents #3 and #4 were not completed timely. |
| Resident #1's support plan was signed by assessor but resident was unable to sign. |
| No documentation that resident #1 and designated person did not object to admission to secured dementia care unit. |
Report Facts
License Capacity: 138
Residents Served: 40
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 15
Hospice Residents: 3
Staff on Duty: 4
Residents Diagnosed with Mental Illness: 15
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Monitors staff sleeping on 2nd and 3rd shifts and conducts periodic visits. | |
| Safety and Maintenance Engineer (SME) | Responsible for monitoring maintenance issues, cleaning schedules, and fire drill records. | |
| Education Coordinator | Conducted audits and monitoring of assessments and support plans. | |
| Licensed Practical Nurse (LPN) or Medical Assistant (MA) | Reviews medication labels and conducts monthly cart audits. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 29, 2022
Visit Reason
The document is a follow-up review of the submitted plan of correction for the facility conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/29/2022.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report
Re-Inspection
Census: 35
Capacity: 35
Deficiencies: 4
Mar 4, 2022
Visit Reason
The inspection was conducted due to a change in the legal entity operating the facility, which is a newly licensed personal care home. The licensing inspector was unable to complete a full inspection and a re-inspection will be conducted within 3 months.
Findings
The facility was found to be in substantial compliance with regulations, but several citations were noted including treatment of residents with dignity, locking of poisonous materials and medications, and maintaining confidentiality of resident records. Plans of correction were accepted and included staff education, suspension of a staff member, and changes to locking mechanisms.
Deficiencies (4)
| Description |
|---|
| Staff person entered resident's bedroom without knocking, causing distress to residents. |
| A full 16 ounce bottle of Isopropyl Rubbing Alcohol was unlocked and accessible to residents not assessed as safe to use poisons. |
| Prescription medications and syringes were unlocked and accessible in the secured dementia care unit medication room. |
| Hospice correspondence and progress notes for residents were unlocked and accessible in a common hallway. |
Report Facts
Total Daily Staff: 50
Waking Staff: 38
Residents Served: 35
License Capacity: 35
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 11
Hospice Residents: 2
Residents Age 60 or Older: 35
Residents with Mobility Need: 15
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
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