Inspection Report
Renewal
Census: 34
Capacity: 46
Deficiencies: 17
May 13, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and regulations.
Findings
The inspection identified multiple deficiencies including issues with posting of current license, carbon monoxide detector placement, staff orientation and training, storage of poisonous materials and food, water pressure, medication administration and record keeping, emergency procedures posting, and resident assessments. Plans of correction were submitted and fully implemented by the follow-up date.
Deficiencies (17)
| Description |
|---|
| License inspection summary was not posted in a conspicuous and public place. |
| Carbon monoxide detectors were installed too close to a gas dryer, violating placement requirements. |
| Direct care staff person C did not receive required fire safety orientation on the first day. |
| Direct care staff person C did not receive orientation on resident rights, emergency medical plan, and mandatory reporting within 40 working hours. |
| Direct care staff person D did not receive medication self-administration training during the 2024 training year. |
| Unknown green liquid was stored in an unlabeled Aquafina water bottle in a public bathroom. |
| Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents. |
| No hot water was available at sinks in men's and women's common bathrooms. |
| Resident #2 did not have an operable lamp or other source of lighting at bedside. |
| Numerous cases of water were stored on the floor in the 4th floor storage closet. |
| Numerous open and unsealed food items were present in the 1st floor main kitchen walk-in freezer. |
| Emergency procedures for the home and municipality were not posted in a conspicuous and public place. |
| Resident #1's prescribed medication Tramadol was not present and available for administration. |
| Resident #1's prescribed medication Lorazepam was not indicated on the May 2025 medication administration record. |
| Resident #1's prescribed Lidocaine patch was not administered due to medication unavailability. |
| Resident #2 and #3 had diagnoses not properly indicated on their assessments. |
| Resident #1 had diagnoses not included on the most recent assessment. |
Report Facts
License Capacity: 46
Residents Served: 34
Staff: 50
Waking Staff: 38
Hospice Residents: 4
Residents 60 or Older: 34
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 32
Capacity: 46
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection visit was conducted as a complaint and incident investigation at THE RESIDENCE AT WHITEHALL.
Findings
The inspection found deficiencies related to failure to provide appropriate assistance with activities of daily living, specifically toileting care, and failure to update resident assessments to reflect significant changes in care needs. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related and incident-driven. The complaint involved failure to respond properly to a resident's call pendant and failure to provide required toileting assistance. The complaint was substantiated as deficiencies were found and plans of correction accepted.
Deficiencies (2)
| Description |
|---|
| Failure to provide assistance with activities of daily living as indicated in the resident’s support plan, including inadequate response to call pendant and toileting assistance. |
| Failure to update resident assessments to reflect significant changes in care needs requiring secured dementia care. |
Report Facts
License Capacity: 46
Residents Served: 32
Current Hospice Residents: 4
Residents with Mental Illness: 1
Residents with Mobility Need: 8
Staffing Hours: 40
Waking Staff: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| J'nai Best | Wellness Director | Completed audit of resident file and conducted staff training related to additional assessment deficiency. |
Inspection Report
Renewal
Census: 35
Capacity: 46
Deficiencies: 18
Nov 28, 2023
Visit Reason
The inspection was conducted as a renewal review of THE RESIDENCE AT WHITEHALL facility on 11/28/2023 and 11/29/2023 to determine compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including issues with DHS access to records, record confidentiality breaches, lack of carbon monoxide alarms near fuel-burning devices, privacy violations related to electronic monitoring, incomplete criminal background checks for staff, inadequate fire safety orientation, medication storage and labeling errors, improper hot water temperatures, incomplete fire drill documentation, and deficiencies in resident support plans. Plans of correction were accepted or directed with proposed completion dates and monitoring plans.
Deficiencies (18)
| Description |
|---|
| Delayed provision of staff person A's record to the Department upon request. |
| Resident records confidentiality breached due to unlocked chart room and exposed resident information. |
| No carbon monoxide alarms located near natural gas fueled boilers and dryers. |
| Unauthorized electronic monitoring signs posted outside resident rooms without proper consent. |
| Criminal background checks missing for several staff members at time of hire. |
| Ancillary and direct care staff did not receive required fire safety and emergency preparedness orientation. |
| Direct care staff training records incomplete, missing full dates for required annual trainings. |
| Poisonous materials not locked and accessible to residents not assessed as safe with poisons. |
| Hot water temperature exceeded 120°F in multiple resident room sinks. |
| No operable lamp or lighting source at bedside in resident room #420. |
| Fire drill records lacked specific exit route information for multiple drills. |
| Fire drill during sleeping hours not conducted every six months as required. |
| Medication storage included expired insulin pen used on resident #7. |
| Prescription medication container lacked pharmacy label for resident #7's insulin pen. |
| Glucometer not calibrated correctly and medication administration record inaccurately documented for resident #8. |
| No documentation that residents #7, #8, and #9 were educated on their right to refuse medication. |
| Resident support plans did not specify type of assistance required for evacuation in emergencies for residents #7, #8, and #9. |
| Resident #10's bedside mobility device use and risks not documented in support plan; device removed pending documentation. |
Report Facts
License Capacity: 46
Residents Served: 35
Total Daily Staff: 37
Waking Staff: 28
Hot Water Temperature: 129.1
Hot Water Temperature: 128
Hot Water Temperature: 126.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Hess | Business Office Manager | Completed all PC staff criminal background checks. |
| Jody Boedigheimer | Wellness Director | Reviewed and revised electronic monitoring policy; provided education and monitoring. |
| Shane Daly | Maintenance Director | Provided fire safety and emergency preparedness training. |
| Harold Hicks | Fire Protection Engineer | Provided fire safety education on exit routes and safe zones. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 46
Deficiencies: 0
Sep 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation at THE RESIDENCE AT WHITEHALL on 09/19/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 46
Residents Served: 34
Current Residents in Hospice: 4
Residents Age 60 or Older: 34
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 30
Capacity: 46
Deficiencies: 7
Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction for the facility.
Findings
The inspection identified multiple deficiencies related to fire safety inspections and drills, medication administration, and medication security. The facility submitted plans of correction which were reviewed and determined to be fully implemented.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and the visit being unannounced.
Deficiencies (7)
| Description |
|---|
| The most recent fire safety inspection and supervised fire drill were not completed annually within the required timeframe. |
| Fire drill records lacked required details including number of residents present, evacuated, staff participating, and fire alarm status. |
| Fire drills during sleeping hours were not conducted every six months as required. |
| Fire drills were not held on different days and times to avoid routine scheduling when staff presence or resident attendance was low. |
| Medications were left unlocked and unattended in resident bedrooms, and residents unable to self-administer medications were not observed taking them. |
| Prescription medications and syringes were not kept locked and accessible only to authorized personnel. |
| A staff person had not completed required annual practicum for medication administration despite completing initial training. |
Report Facts
License Capacity: 46
Residents Served: 30
Current Residents in Hospice: 5
Residents Age 60 or Older: 30
Residents with Mobility Need: 7
Unattended Pills in Resident #3 Bedroom: 10
Unattended Pills in Resident #4 Bedroom: 4
Total Daily Staff: 37
Waking Staff: 28
Inspection Report
Renewal
Census: 35
Capacity: 46
Deficiencies: 6
Apr 13, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of THE RESIDENCE AT WHITEHALL on 04/13/2022 and 04/14/2022.
Findings
Several deficiencies were identified including lack of emergency telephone numbers posted, soap dispenser malfunction, obstructed emergency exit door, expired medication storage, uncalibrated glucometer, and unsigned resident contract. All deficiencies had plans of correction accepted and were verified as corrected by the inspector prior to exit.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and findings related to medication storage and emergency preparedness.
Deficiencies (6)
| Description |
|---|
| No emergency telephone numbers posted on or nearby the telephone in the 4th floor living room. |
| No soap available in the 4th floor men's bathroom soap dispenser. |
| Emergency exit door located in the 1st floor laundry room was stuck shut and required force to open. |
| Expired medication found on the medication cart with expiration date 1/21/2022. |
| Resident #3's glucometer was not calibrated to the current date and time. |
| Resident #1's contract was not signed by the resident; repeat violation from 5/18/2021. |
Report Facts
License Capacity: 46
Residents Served: 35
Staffing Hours: 43
Waking Staff: 32
Current Hospice Residents: 11
Residents Age 60 or Older: 35
Residents with Mobility Need: 8
Deficiencies Cited: 6
Notice
Capacity: 46
Deficiencies: 0
Jul 30, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Residence at Whitehall Personal Care Home, with a reminder that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms the issuance of a license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Total licensed capacity: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 29
Capacity: 46
Deficiencies: 27
May 18, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted from 05/18/2021 to 05/20/2021 to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies related to contract signatures, criminal background checks, staff qualifications and training, sanitary conditions, food safety, medication management, and resident assessments. Plans of correction were submitted and accepted for most deficiencies, with some initially not accepted but later corrected. The facility demonstrated compliance with corrective actions by the time of the report.
Deficiencies (27)
| Description |
|---|
| Resident #2’s contract was not signed by the resident. |
| Criminal history checks were not completed timely for staff persons A and B. |
| Direct care staff person C lacked documentation of a high school diploma, GED, or active registry status. |
| Direct care staff person D provided unsupervised personal care without completing required training and competency test. |
| Staff persons B, C, D, and E lacked training in evacuation procedures, fire safety, resident rights, emergency medical plans, and mandatory reporting. |
| Poisonous materials were stored in unlabeled containers. |
| Sanitary conditions were not maintained; dirty dish towels and mop water were improperly stored. |
| Trash receptacles in kitchens, bathrooms, and outside were uncovered. |
| Fire doors near the 4th floor Wellness Center did not close completely. |
| Hot water temperature at an accessible hand sink exceeded 120°F. |
| First aid kit in medication room lacked a CPR breathing shield. |
| An operable lamp was not plugged in at bedside in apartment #429. |
| Food was not protected from contamination; uncovered cream pie slices were found. |
| Leftover food items were undated and uncovered in the kitchen. |
| Refrigerator/freezer lacked a thermometer in the freezer compartment. |
| Food was stored in unsealed containers; ice cream tubs were uncovered. |
| Outdated or unlabeled food items were found in the walk-in freezer and cupboards. |
| Initial medical evaluation for resident #4 was not completed within required timeframe. |
| Menus were not posted one week in advance. |
| Resident #1’s assessment incorrectly indicated inability to self-administer medications despite evidence to the contrary. |
| Medications were not stored properly; insulin pens were not dated when opened. |
| Prescription medication labeling was inaccurate; discontinued prn orders were not updated. |
| Resident #1’s blood glucose monitoring records were incomplete and glucometer histories were erased/reset. |
| Medication record for resident #4 lacked strength information for a prescribed medication. |
| Staff person G administered insulin without completing required diabetes education. |
| Resident #1’s and resident #5’s annual assessments were not updated to reflect changes in diet and supervision needs. |
| Resident #1’s support plan was not signed by the assessor. |
Report Facts
License Capacity: 46
Residents Served: 29
Staffing Hours: 36
Waking Staff: 27
Current Residents on Hospice: 2
Residents with Mobility Need: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in criminal background check deficiency. | |
| Staff person B | Named in criminal background check and training deficiencies. | |
| Staff person C | Named in training and qualification deficiencies. | |
| Staff person D | Named in training and competency deficiencies. | |
| Staff person E | Registered Nurse | Named in training deficiencies. |
| Staff person F | Named in medication self-administration deficiency. | |
| Staff person G | Direct care and medication technician | Named in insulin administration deficiency. |
| Administrator | Named in multiple corrective action monitoring roles. | |
| Wellness Director | Named in multiple corrective action monitoring roles. | |
| Dining Services Director | Named in food safety and sanitation corrective actions. | |
| Maintenance Director | Named in monitoring compliance with poisonous materials and trash receptacles. |
Inspection Report
Follow-Up
Census: 15
Capacity: 46
Deficiencies: 4
Apr 8, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/08/2021 to review the submitted plan of correction related to an incident involving alleged resident abuse and safeguarding issues.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the failure to report suspected abuse timely, failure to suspend or supervise the alleged staff involved, and lack of a system to safeguard residents' money and property. Continued compliance is required.
Complaint Details
The visit was complaint-related involving an allegation by resident #1 that staff person A took $60.00 from the resident's bedroom on 3/14/2021. The incident was not reported timely, and staff person A was not suspended or supervised following the allegation. The complaint was substantiated with findings of delayed reporting and inadequate safeguards.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by law. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report the incident to the Department within 24 hours as required. |
| Lack of a system to safeguard residents' money and property; no lockboxes or secured storage provided. |
Report Facts
License Capacity: 46
Residents Served: 15
Amount Allegedly Stolen: 60
Dates Staff Person A Worked Unsupervised: 3
Completion Date of Plan of Correction: Apr 20, 2021
Estimated Lock Installation Date: May 26, 2021
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