Inspection Reports for The Terrace At Chestnut Hill
495 E Abington Ave, Philadelphia, PA 19118, United States, PA, 19118
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Inspection Report
Renewal
Census: 85
Capacity: 122
Deficiencies: 7
Dec 16, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE TERRACE AT CHESTNUT HILL on 12/16/2024 and 12/17/2024.
Findings
The inspection identified several sanitary and safety deficiencies including unclean furniture, feces smeared on a bathroom toilet seat, strong urine odor in a memory care area, exposed trash can lids with food spills, multiple tripping hazards on the outdoor patio, and grease buildup on kitchen surfaces. Plans of correction were submitted and fully implemented by February 20, 2025.
Deficiencies (7)
| Description |
|---|
| Couch in memory care #2 was unclean with food stains. |
| Arms of the blue floral print chair were soiled with stains. |
| Male common area bathroom toilet seat had feces smeared on it. |
| Strong smell of urine located on Memory Care #4 area of the home. |
| Lid of trash can was exposed with an unclean surface of food spills; plastic lids covering ice cream had stains of spilled ice cream. |
| Outdoor patio area had multiple tripping hazards including overturned table and umbrella stand with protruding parts. |
| Side of the oven between the cooktop and deep fryer was covered in grease and grime, posing a fire hazard. |
Report Facts
License Capacity: 122
Residents Served: 85
Memory Care Unit Capacity: 45
Memory Care Residents Served: 26
Hospice Residents: 9
Residents with Mobility Need: 31
Residents 60 Years or Older: 84
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Census: 86
Capacity: 122
Deficiencies: 0
Nov 20, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 111
Waking Staff: 83
License Capacity: 122
Residents Served: 86
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 8
Residents Age 60 or Older: 85
Residents with Mobility Need: 25
Inspection Report
Follow-Up
Census: 83
Capacity: 122
Deficiencies: 2
Sep 27, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to a complaint and incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details two deficiencies: one involving resident abuse resulting in a hip fracture, and another involving incomplete documentation in a resident's support plan for medical needs.
Complaint Details
The visit was complaint-related and incident-driven, involving a resident abuse incident witnessed on the elevator that resulted in injury and hospitalization.
Deficiencies (2)
| Description |
|---|
| Resident abuse incident where two residents were fighting on an elevator, resulting in one resident falling and sustaining a hip fracture. |
| Resident's support plan did not document how medical diagnoses would be met, constituting a repeated violation. |
Report Facts
License Capacity: 122
Residents Served: 83
Memory Care Capacity: 45
Memory Care Residents Served: 25
Current Hospice Residents: 7
Residents Age 60 or Older: 83
Residents with Mobility Need: 34
Inspection Report
Follow-Up
Census: 70
Capacity: 122
Deficiencies: 5
Jan 31, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 01/31/2024 for incident and monitoring purposes to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies previously cited related to locking poisonous materials, lighting, furniture and equipment, leftover food labeling, and medication storage were addressed with corrective actions and staff in-service training.
Deficiencies (5)
| Description |
|---|
| Unlabeled and undistinguishable bar of soap was unlocked, unattended, and accessible to residents in the Memory Care Room, with some residents not assessed as capable of safely using or avoiding poisonous materials. |
| The stairwell to exit 4 near a room was dark; the emergency light was not operable and the ceiling light fixture was not working. |
| The rubber seal at the bottom of the refrigerator in the Memory Care kitchenette was falling off. |
| An unlabeled, undated container of juice was found in the Memory Care kitchenette refrigerator. |
| Two loose pills were found in the Medication Cart serving the 2nd and 3rd floors; tape was found on the back of a blister pack for a resident's prescription tablet. |
Report Facts
License Capacity: 122
Residents Served: 70
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 8
Residents with Mobility Need: 51
Total Daily Staff: 121
Waking Staff: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director | In-serviced on regulation 82C and responsible for twice weekly inspections of poisonous materials | |
| Maintenance Director | In-serviced on lighting and furniture/equipment compliance; responsible for weekly site walks and inspections | |
| Director of Wellness | In-serviced on medication storage; responsible for weekly audits of medication carts | |
| Medication Technicians | In-serviced on medication cart inspections and proper disposal of loose pills and taped blister packs | |
| Nursing Team | In-serviced on medication storage and disposal procedures |
Inspection Report
Renewal
Census: 106
Capacity: 122
Deficiencies: 24
Oct 16, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of THE TERRACE AT CHESTNUT HILL facility on 10/16/2023 and 10/17/2023.
Findings
The inspection identified multiple deficiencies including failure to report suspected resident abuse, medication errors, incomplete medical evaluations and assessments, improper storage of medications, inadequate documentation of support plans, and safety hazards such as blocked egress and water pressure issues. Plans of correction were accepted and implemented by 02/12/2024.
Deficiencies (24)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident involving a cut caused by a broken vase. |
| Failure to report medication errors involving insulin administration and blood sugar monitoring. |
| Resident abuse involving aggressive behavior and inadequate response to resident aggression. |
| Violation of resident privacy during medication administration in a common area. |
| Low water pressure in room 302. |
| Clogged toilet in second-floor women's bathroom. |
| No toilet paper available in first-floor women's bathroom. |
| Freezer temperature recorded at 14 degrees Fahrenheit, above required 0°F. |
| Blocked egress due to a thick fuzzy mat preventing door from opening fully. |
| Lack of documentation of written notification to local fire department regarding emergency evacuation. |
| Incomplete medical evaluations missing physical exam, immunization history, allergy information, and mobility assessments. |
| Failure to complete annual medical evaluations timely for several residents. |
| Improper storage of unopened insulin pen without date indicating time out of refrigeration. |
| Incorrect documentation of glucometer readings and missing medications on medication cart. |
| Failure to follow prescriber's orders for insulin administration based on blood sugar readings. |
| Failure to immediately report medication errors to resident, designated person, and prescriber. |
| Preadmission screening forms missing determination that resident needs can be met by the home. |
| Initial assessments not completed within 15 days of admission or missing key assessment elements. |
| Additional assessments missing or incomplete for eating, agitation, aggression, and diagnoses. |
| Support plans not completed timely or missing documentation of how resident needs will be met. |
| Resident without primary dementia diagnosis residing in secured dementia care unit unable to operate locking mechanism. |
| Admission support plan not developed within 72 hours of admission to secured dementia care unit. |
| Support plan missing identification of resident's physical, medical, social, cognitive, and safety needs. |
| Support plan missing documentation of resident's ability to self-administer medications or need for reminders. |
Report Facts
License Capacity: 122
Residents Served: 106
Secured Dementia Care Unit Capacity: 76
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 6
Residents with Mobility Need: 40
Residents Age 60 or Older: 106
Total Daily Staff: 146
Waking Staff: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | In-serviced staff on multiple deficiencies and oversaw plans of correction. | |
| Director of Wellness | In-serviced staff, conducted audits, and monitored compliance with medication administration and assessments. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 122
Deficiencies: 3
Jun 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Findings
The inspection found deficiencies related to annual medical evaluations, additional assessments lacking assessor information, and missing resident signatures on support plans. Plans of correction were accepted and implemented by July 14, 2023.
Complaint Details
The visit was complaint-related and included an incident investigation. The submitted plan of correction was fully implemented as of the last review dates.
Deficiencies (3)
| Description |
|---|
| Resident 1’s most recent medical evaluation was not completed as required annually. |
| The assessment for resident 2 did not indicate the assessor's name, title, signature, or date signed. |
| Resident 2 participated in the development of the support plan but did not sign the support plan. |
Report Facts
License Capacity: 122
Residents Served: 78
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 5
Residents 60 Years or Older: 78
Residents Diagnosed with Intellectual Disability: 3
Residents Diagnosed with Physical Disability: 12
Residents with Mobility Need: 41
Inspection Report
Census: 77
Capacity: 122
Deficiencies: 0
May 9, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 120
Waking Staff: 90
Resident Support Staff: 0
License Capacity: 122
Residents Served: 77
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 29
Current Hospice Residents: 5
Residents Age 60 or Older: 77
Residents with Mobility Need: 43
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 85
Capacity: 122
Deficiencies: 3
Feb 22, 2023
Visit Reason
The inspection visit on 02/22/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the review date. The report details a serious abuse incident involving a staff member who was terminated, as well as deficiencies related to direct care staff qualifications and training, all of which have been addressed with corrective actions and ongoing monitoring.
Deficiencies (3)
| Description |
|---|
| Staff Member A verbally abused a resident and spit in the resident's face, resulting in immediate termination and police involvement. |
| Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person A provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
Report Facts
License Capacity: 122
Residents Served: 85
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 33
Hospice Residents: 9
Residents 60 Years or Older: 82
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 54
Residents with Physical Disability: 1
Total Daily Staff: 139
Waking Staff: 104
Inspection Report
Complaint Investigation
Census: 88
Capacity: 122
Deficiencies: 20
Jan 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site and off-site review dates to assess compliance and follow-up on a plan of correction submission.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, neglect and abuse of residents, staff sleeping on duty, inadequate staff training, unsafe storage of poisonous materials, unsanitary conditions, communication system failures, incomplete medical evaluations, improper medication management, lack of written service procedures, incomplete resident assessments, and insufficient activities offered on memory care units.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and abuse, including failure to meet personal care needs of resident #2 during overnight shifts and staff sleeping on duty. The complaint was substantiated based on interviews and observations.
Deficiencies (20)
| Description |
|---|
| Failure to report an unwitnessed fall incident involving resident #1 to the Department within 24 hours. |
| Neglect and abuse of resident #2 during overnight shifts, including unmet toileting needs and sleeping staff. |
| Overnight staff sleeping while on duty despite requirement to be awake when 16 or more residents are present. |
| Staff training plan did not include Mechanical Hoyer Lift, Ostomy Care, and Urinary Catheter Care. |
| Poisonous materials (A&D Ointment and Prang Paint) were unlocked and accessible to residents in memory care unit. |
| Unsanitary conditions due to unlabeled towels and washcloths in shared living space. |
| Floors and ceilings in certain areas were unclean or in need of repair. |
| Lack of a communication system enabling staff to contact each other immediately in emergencies. |
| Broken and missing locks on cabinets in the 2nd floor memory care kitchen. |
| Medical evaluations for residents #2 and #5 were incomplete, missing vital signs and immunization history. |
| Menus were not posted timely and meal substitutions were not properly communicated to residents. |
| Resident #5 self-administers medications including insulin but lacked physician assessment for ability and reminders. |
| Discontinued medications were improperly stored on medication cart. |
| Glucagon Kit medication for resident #7 was not available in the home. |
| Written description of services and activities did not include scope, admission, and discharge criteria. |
| Lack of written procedures for delivery and management of services from admission to discharge, including ostomy and urinary catheter care. |
| Resident #2 and #5 had outdated assessments not completed annually or upon significant change. |
| Resident #8 did not sign the support plan despite participation in its development. |
| Direct care staff person D did not receive required annual dementia training for 2022. |
| Activities were not offered as scheduled on memory care units due to limited staff. |
Report Facts
Residents present: 88
Total licensed capacity: 122
Memory care unit capacity: 45
Memory care residents served: 34
Hospice residents: 6
Residents aged 60 or older: 86
Residents with mobility need: 21
Residents with mental illness: 3
Total daily staff: 109
Waking staff: 82
Inspection Report
Renewal
Census: 80
Capacity: 122
Deficiencies: 12
Aug 15, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection with an incident, conducted on 08/15/2022 and 08/16/2022 to assess compliance with licensing regulations and incident follow-up.
Findings
The facility had multiple deficiencies including failure to provide a current quality management plan, unsecured poisonous materials, unsanitary conditions in resident rooms and bathrooms, broken fixtures posing safety hazards, missing emergency telephone numbers, inoperable lamps, lack of toilet paper in bathrooms, improper refrigerator/freezer temperatures, insufficient emergency food supply, missing or outdated emergency management procedures, and medication storage and documentation issues. All deficiencies were corrected on-site or through submitted plans of correction with education and training provided to staff.
Deficiencies (12)
| Description |
|---|
| The home did not provide the current or previous quality management plan. |
| Poisonous materials were found unsecured and accessible to residents on the Secure Dementia Unit. |
| Multiple bedrooms and bathrooms were found soiled, unclean, and smelling like feces. |
| Broken switch or nozzle in bathroom posing a safety hazard. |
| No emergency telephone numbers posted near telephones in resident bedrooms. |
| Lamps in resident bedrooms were not plugged in or operable. |
| Toilet paper was not provided for a toilet in a resident bathroom. |
| Walk-in freezer temperatures exceeded regulatory limits during inspection and prior logs. |
| The home did not maintain at least a 3-day supply of nonperishable food and drinking water. |
| The home did not provide current or previously approved written emergency procedures. |
| Medication audit revealed a medication on the med-cart without a current order for a resident. |
| Procedures for safe storage, access, security, distribution and use of medications and medical equipment were not properly implemented; missing medications and documentation errors were found. |
Report Facts
License Capacity: 122
Residents Served: 80
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 34
Hospice Residents: 7
Residents 60 Years or Older: 77
Residents with Mobility Need: 51
Residents with Physical Disability: 3
Staffing Hours - Total Daily Staff: 131
Staffing Hours - Waking Staff: 98
Emergency Food Stock - Vanilla Pudding Cases: 4
Emergency Food Stock - Peaches Cases: 6
Emergency Food Stock - Apple Sauce Cases: 5
Emergency Food Stock - Mixed Vegetables Cases: 4
Emergency Food Stock - String Beans Cases: 1
Emergency Food Stock - 3 Bean Salad Cases: 3
Emergency Food Stock - Corn Cases: 3
Emergency Food Stock - Ravioli Cases: 3
Emergency Food Stock - Beef Stew Cases: 4
Emergency Food Stock - Cornbeef Hash Cases: 2
Emergency Food Stock - Pears Cases: 3
Emergency Food Stock - Pineapples Cases: 3
Emergency Food Stock - Fruit Cocktail Cases: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bill Snow | Legal Entity Contact | Listed as contact for ABINGTON SENIOR CARE LLC |
| Director of Nursing | Named in relation to ensuring proper storage of poisonous materials and medication cart audits | |
| Memory Care Director | Named in relation to environmental rounds for poisonous materials | |
| Executive Director | Responsible for oversight of quality management meetings, emergency management plan submission, and corrective actions | |
| Facilities Engineer | Responsible for environmental rounds, emergency management plan submission, and facility maintenance | |
| Director of Sales & Marketing | Responsible for ensuring emergency telephone numbers are posted | |
| Medicine Technicians | Educated on medication matching and documentation policies | |
| Staff Person A | Mentioned in relation to quality management plan and emergency procedures knowledge | |
| Staff Person B | Terminated following medication investigation |
Inspection Report
Follow-Up
Census: 78
Capacity: 122
Deficiencies: 4
Jun 14, 2022
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident and other compliance issues at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to resident abuse reporting, abuse incidents involving staff misuse of resident credit cards, and incomplete resident support plans were addressed with staff education and updated documentation.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected resident abuse in writing to the local area agency on aging as required. |
| Staff person A used a resident's credit card without permission to order food for themselves, constituting abuse and theft. |
| Resident #2 had self-inflicted cuts that were not identified in the resident's support plan, and staff were unaware of the resident's risk for self-harm. |
| Resident support plans did not document medical, dental, vision, hearing, mental health or behavioral care needs or plans to meet those needs. |
Report Facts
License Capacity: 122
Residents Served: 78
Memory Care Capacity: 45
Memory Care Residents Served: 34
Current Hospice Residents: 6
Staff Total Daily: 126
Waking Staff: 95
Residents Age 60 or Older: 76
Residents with Mobility Need: 48
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 23
Capacity: 33
Deficiencies: 8
Sep 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to address specific concerns at THE BRYN MAWR TERRACE facility.
Findings
Multiple deficiencies were found including incomplete staff orientation documentation, unsecured poisonous materials accessible to residents, unsanitary conditions in resident rooms, locked resident bedrooms denying access, lack of operable bedside lamps, improper food storage and labeling, unlocked medications, and delayed resident assessments and support plan revisions.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission scheduled. Specific complaint details are not explicitly stated beyond the reason for inspection.
Deficiencies (8)
| Description |
|---|
| Staff orientation training documentation was not signed or dated to confirm completion. |
| Poisonous materials such as fluoride toothpaste, creams, lotions, and antibiotic soap were unlocked and accessible to residents in the Secure Dementia Unit. |
| Nebulizer unit nozzle found on floor and feces smeared on toilet seat and bedspread after cleaning in resident rooms. |
| Resident bedrooms were locked denying access to residents who do not have keys in the Secure Dementia Unit. |
| Resident did not have access to an operable lamp or source of lighting at bedside. |
| Unlabeled and undated leftover food and unsealed food items found in the Secure Dementia Care Unit kitchen refrigerator. |
| Prescription medications and treatment lotions were unlocked and accessible in resident rooms. |
| Resident #2's annual assessment and support plan revisions were completed late. |
Report Facts
License Capacity: 33
Residents Served: 23
Residents Served in Secured Dementia Care Unit: 17
Staffing Hours - Total Daily Staff: 40
Staffing Hours - Waking Staff: 30
Follow-Up Date: Sep 28, 2021
Notice
Capacity: 122
Deficiencies: 0
Jul 21, 2021
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it is a license renewal letter and certificate of compliance confirming the facility's authorized operation and capacity.
Report Facts
Maximum licensed capacity: 122
Secure Dementia Care Unit capacity: 45
Inspection Report
Complaint Investigation
Census: 62
Capacity: 122
Deficiencies: 5
Jul 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates, culminating in a partial on-site inspection on 07/13/2021.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, inadequate mattress condition, failure to assist with transportation to medical appointments, refusal of medication documentation issues, and failure to follow prescriber's medication orders. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and multiple off-site reviews leading to a partial on-site inspection.
Deficiencies (5)
| Description |
|---|
| Failure to report incidents to the Department within 24 hours, including a resident injury and death. |
| Resident assigned an uncomfortable and inoperable bed; durable medical equipment was not properly managed or labeled. |
| Failure to assist resident with transportation to medical appointments, resulting in missed appointments. |
| Lack of documentation and physician response for resident's refusal of prescribed medication on multiple occasions. |
| Medication prescribed to resident was not administered due to unavailability in the home. |
Report Facts
License Capacity: 122
Residents Served: 62
Memory Care Capacity: 45
Memory Care Residents Served: 24
Hospice Residents: 9
Resident Age 60 or Older: 62
Residents with Mobility Need: 24
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandi Wooters | Signed the letter confirming plan of correction implementation. | |
| Director of Wellness | Named in multiple plans of correction related to incident reporting, equipment management, medication refusal, and medication administration. | |
| Memory Care Director | Involved in equipment management and medication refusal follow-up. | |
| Executive Director | Responsible for oversight of plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 122
Deficiencies: 5
Jul 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review citations found during multiple licensing inspections on various dates including 07/13/2021.
Findings
The report identified multiple deficiencies including failure to report incidents within 24 hours, inadequate bed conditions, failure to assist with transportation to medical appointments, refusal of medication documentation issues, and failure to follow prescriber's orders regarding medication administration.
Complaint Details
The inspection was complaint-driven, as indicated by the inspection reason and partial inspection type. The report includes substantiated deficiencies related to incident reporting, medication administration, transportation assistance, and equipment issues.
Deficiencies (5)
| Description |
|---|
| Failure to report incidents or conditions to the Department within 24 hours as required. |
| Resident was provided an uncomfortable and inoperable bed that was not the one assigned by the durable medical equipment company. |
| Failure to assist resident with coordination of transportation to medical appointments, resulting in missed appointments. |
| Failure to document and report resident's refusal of prescribed medication to the physician. |
| Failure to follow prescriber's orders by not administering prescribed medication due to unavailability. |
Report Facts
License Capacity: 122
Residents Served: 62
Memory Care Capacity: 45
Memory Care Residents Served: 24
Current Residents in Hospice: 9
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 24
Residents 60 Years or Older: 62
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandi Wooters | Signed the cover letter regarding the inspection results. | |
| Bill Snow | Contact person for ABINGTON SENIOR CARE LLC mentioned in the letter. |
Inspection Report
Renewal
Census: 54
Capacity: 122
Deficiencies: 6
Jun 8, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection with a complaint component conducted on 06/08/2021 to assess compliance with licensing regulations and facility standards.
Findings
The inspection identified multiple deficiencies related to posting of licenses and emergency procedures, bedroom furnishings such as chairs and lighting, soap dispensers, and menu postings. All violations were corrected on the day of the inspection with plans of correction implemented and documented.
Complaint Details
The inspection included a complaint investigation component as noted in the inspection reason, but no substantiation status or further complaint details were provided.
Deficiencies (6)
| Description |
|---|
| The home did not have the license inspection summary or the 2600 regulation book posted in a conspicuous and public place. |
| Bedroom #302 was occupied by two residents but lacked a chair for one resident. |
| Resident #2 did not have access to a source of light that can be turned on/off at bedside in their bedroom. |
| The bathroom in room #302 did not have soap. |
| The home’s emergency procedures were not posted in a conspicuous and public place. |
| The home did not have a menu posted on the 2nd or 3rd floor Secured Dementia Care Unit (SDCU). |
Report Facts
License Capacity: 122
Residents Served: 54
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Residents Age 60 or Older: 50
Residents with Mobility Need: 35
Residents with Physical Disability: 4
Total Daily Staff: 89
Waking Staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter regarding plan of correction implementation | |
| Business Office Director | Named as primary responsible party for ensuring posting of license inspection summary, emergency procedures, and compliance | |
| Executive Director | Named as secondary or tertiary responsible party for multiple deficiencies including posting and compliance | |
| Director of Sales | Named as primary responsible party for ensuring bedside chairs compliance | |
| Maintenance Assistant | Named as secondary responsible party for bedside chairs, lighting, and soap dispenser compliance | |
| Memory Care Director | Named as secondary responsible party for soap dispenser and menu posting compliance | |
| Director of Dining Services | Named as primary responsible party for menu posting compliance |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 122
Deficiencies: 2
Feb 2, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with care requirements at THE TERRACE AT CHESTNUT HILL.
Findings
The facility was found to have deficiencies related to personal hygiene and securing preventative dental care for a resident. The plan of correction was accepted and implemented, with follow-up documentation submitted.
Complaint Details
The inspection was complaint-driven, with the complaint reason explicitly stated. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1 did not receive assistance with hair grooming or oral hygiene as required by the assessment and support plan. |
| The home did not arrange dental care for resident #1 after a tooth fell out in June 2020, despite the care plan indicating assistance with dental appointments. |
Report Facts
License Capacity: 122
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 18
Current Residents in Hospice: 4
Residents 60 Years or Older: 47
Residents with Mental Illness: 1
Residents with Physical Disability: 4
Residents with Mobility Need: 38
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