Inspection Report
Complaint Investigation
Census: 53
Capacity: 92
Deficiencies: 1
Apr 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with resident care regulations.
Findings
The facility was found to have not followed a resident's diet order change from a mechanical soft diet to a regular diet starting 1/31/25, continuing the mechanical soft diet until discharge. The facility disputed the violation, citing compliance with medical evaluations and orders from the resident's primary care providers.
Complaint Details
The visit was complaint-related as stated under Inspection Information with reason 'Complaint'. The facility disputed the finding and submitted a plan of correction.
Deficiencies (1)
| Description |
|---|
| The home did not follow resident diet order change to a regular diet beginning on 1/31/25; the resident continued to receive a mechanical soft diet until discharge. |
Report Facts
License Capacity: 92
Residents Served: 53
Staffing Hours - Total Daily Staff: 53
Staffing Hours - Waking Staff: 40
Inspection Report
Renewal
Census: 44
Capacity: 92
Deficiencies: 6
Dec 18, 2024
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation, with exit conference held on 12/23/2024.
Findings
The facility was found to have multiple deficiencies including missing window coverings in a resident room, an overdue annual fire safety inspection and drill, unlocked medication cart, missing PRN medication in the cart, incorrect medication record documentation, and disputed grounds for resident discharge related to payment issues. All deficiencies had plans of correction submitted and were marked as implemented by 03/05/2025.
Complaint Details
The complaint involved a resident's unpaid payment due to a Social Security Administration error discontinuing the facility as the resident’s representative payee. The facility disputed the finding of failure to make reasonable documented efforts to obtain payment, providing extensive documentation of attempts to resolve the issue.
Deficiencies (6)
| Description |
|---|
| The window in room #1 did not have a window covering, shades, drapes, blinds, or shutters on the bedroom window. |
| The home’s annual fire safety inspection and supervised fire drill was conducted more than 1 year and 15 days after the previous one. |
| The medication cart located closest to the windows in the dining room was found unlocked with no staff present. |
| Resident #1's PRN Acetaminophen 325mg Tablets medication was not in the cart at the time of inspection. |
| Resident #2's Medication Administration Record incorrectly noted an Albuterol Nebulizer instead of the prescribed Albuterol HFA Inhaler. |
| The home was cited for not making reasonable documented efforts to obtain payment after Resident #3’s social security check did not arrive, though the facility disputed this finding. |
Report Facts
License Capacity: 92
Residents Served: 44
Staffing Hours: 44
Waking Staff: 33
Hospice Residents: 1
Residents with Mental Illness: 12
Residents with Intellectual Disability: 4
Residents with Physical Disability: 2
Unpaid Balance: 1712
Inspection Report
Complaint Investigation
Census: 45
Capacity: 92
Deficiencies: 2
Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations following a complaint.
Findings
Two deficiencies were found: a violation of resident privacy during medical procedures where blood sugar checks and insulin administration were performed at the dining table, and failure to post the weekly menu for the following week in a timely manner. Both deficiencies were corrected with plans of correction implemented by 10/15/2024.
Complaint Details
The visit was complaint-related and unannounced. The complaint triggered the inspection on 08/29/2024. The submitted plan of correction was fully implemented and accepted.
Deficiencies (2)
| Description |
|---|
| Resident privacy violation during medical procedures conducted at the lunch table in the presence of other residents. |
| Failure to post the weekly menu for the following week in a conspicuous place, as required. |
Report Facts
Residents Served: 45
License Capacity: 92
Current Residents in Hospice: 2
Residents Receiving Supplemental Security Income: 4
Residents Diagnosed with Mental Illness: 11
Residents Diagnosed with Intellectual Disability: 4
Residents Age 60 or Older: 44
Residents with Physical Disability: 2
Residents with Mobility Need: 0
Inspection Report
Complaint Investigation
Census: 57
Capacity: 92
Deficiencies: 0
Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/26/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
Residents Served: 57
License Capacity: 92
Total Daily Staff: 57
Waking Staff: 43
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 12
Residents Diagnosed with Intellectual Disability: 4
Residents Receiving Supplemental Security Income: 4
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 46
Capacity: 92
Deficiencies: 1
Apr 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on April 9, 2024.
Findings
The inspection found a violation related to obstructed egress where the main exit door was blocked by a velvet rope attached to metal stands. The issue was immediately corrected by moving and then removing the stanchions to ensure unobstructed emergency exits.
Complaint Details
The visit was complaint-related and the submitted plan of correction was fully implemented as of the inspection date.
Deficiencies (1)
| Description |
|---|
| The main exit/entrance door on the 1st floor was obstructed by a velvet rope attached to two metal stands that spanned the entire width of the door. |
Report Facts
License Capacity: 92
Residents Served: 46
Total Daily Staff: 46
Waking Staff: 35
Residents Diagnosed with Mental Illness: 29
Residents Diagnosed with Intellectual Disability: 3
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 46
Inspection Report
Renewal
Census: 46
Capacity: 92
Deficiencies: 7
Jan 17, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing regulations at THE VILLA ST. ELIZABETH facility.
Findings
Multiple deficiencies were identified related to facility safety and sanitation, including uncovered trash receptacles, obstructed egress routes, missing first aid kit items, snow obstructing outdoor steps, improper soap dispenser use, and missing fire extinguisher inspection tags. All deficiencies were corrected immediately or shortly after the inspection, with plans of correction accepted and implemented.
Deficiencies (7)
| Description |
|---|
| Two garbage cans in the kitchen were uncovered with food garbage and no staff present. |
| Towels obstructed the stairwell exit door, posing a tripping hazard and limiting safe egress. |
| First aid kits in the cottages and back room were missing tape, scissors, eye coverings, gauze, tweezers, and a thermometer. |
| Outdoor steps leading to the smoking area were not cleared of snow. |
| A bar of soap was found in a shared bathroom shower stall, violating soap dispenser requirements. |
| The front exit door was obstructed by a velvet rope attached to metal stands spanning the door width. |
| The fire extinguisher on the 2nd floor hallway lacked an inspection tag. |
Report Facts
Residents Served: 46
License Capacity: 92
Total Daily Staff: 46
Waking Staff: 35
Residents Receiving Supplemental Security Income: 4
Residents Diagnosed with Mental Illness: 29
Residents Age 60 or Older: 45
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 48
Capacity: 92
Deficiencies: 1
Oct 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 10/04/2023.
Findings
The report details a disputed deficiency regarding Resident #1's support plan not being updated to reflect certain behaviors and care coordination needs. The facility strongly contests the violation, providing extensive documentation and a plan of correction to ensure ongoing compliance.
Complaint Details
The visit was complaint-related with the reason explicitly stated as 'Complaint'. The facility disputes the finding, asserting no violation occurred and providing a detailed corrective action plan and supporting documentation.
Deficiencies (1)
| Description |
|---|
| Resident #1's support plan was not updated to reflect behaviors related to hoarding, excessive ordering, and coordination with multiple physicians to prevent obtaining additional medication orders. |
Report Facts
License Capacity: 92
Residents Served: 48
Staffing Hours: 48
Waking Staff: 36
Residents Receiving Supplemental Security Income: 4
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 29
Residents Diagnosed with Intellectual Disability: 3
Current Hospice Residents: 0
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Feb 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation at THE VILLA ST. ELIZABETH facility on 02/02/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection Information with Reason: Complaint. No deficiencies or citations were found.
Report Facts
Residents Served: 52
License Capacity: 92
Total Daily Staff: 52
Waking Staff: 39
Residents Receiving Supplemental Security Income: 9
Residents Diagnosed with Mental Illness: 26
Residents Age 60 or Older: 44
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 47
Capacity: 92
Deficiencies: 3
Oct 12, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE VILLA ST. ELIZABETH on 10/12/2022 and 10/13/2022.
Findings
The inspection found three deficiencies related to emergency exit lighting, unobstructed egress, and medication storage. All deficiencies were corrected immediately during the inspection or shortly thereafter, and the submitted plan of correction was fully implemented.
Deficiencies (3)
| Description |
|---|
| The emergency exit located at the rear of the cottage section of the facility did not have a functional exterior lighting source; the light fixture was missing a light bulb. |
| The home’s emergency exit located in the rear of the cottage section of the facility was blocked by a walker placed directly in front of the exit preventing immediate egress. |
| Resident #1’s 100 unit Lantus Insulin pen, to be administered 14 units IM at bedtime, was not dated when opened due to smudged ink. |
Report Facts
License Capacity: 92
Residents Served: 47
Staffing Hours: 47
Waking Staff: 35
Supplemental Security Income recipients: 4
Residents 60 Years or Older: 45
Residents Diagnosed with Mental Illness: 29
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Property Manager | Placed new light bulb immediately during inspection | |
| Resident Care Manager | Moved walker blocking emergency exit immediately during inspection | |
| Administrator | Responsible for ongoing compliance and re-marked insulin pen with proper open date |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 92
Deficiencies: 0
Sep 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 09/06/2022, 09/09/2022, and 09/12/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
Residents Served: 47
License Capacity: 92
Total Daily Staff: 47
Waking Staff: 35
Residents Diagnosed with Mental Illness: 24
Residents 60 Years or Older: 42
Residents Receiving Supplemental Security Income: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 3
Inspection Report
Routine
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 49
Capacity: 92
Deficiencies: 5
Sep 21, 2021
Visit Reason
The inspection was a renewal visit conducted on 09/21/2021 and 09/22/2021 to review compliance with licensing regulations at THE VILLA ST. ELIZABETH.
Findings
The inspection identified several deficiencies including a resident privacy violation due to unredacted information on a posted inspection summary, incomplete medical evaluations for residents, medication administration training lapses for staff, improper storage of medications, and errors in medication administration records. All deficiencies had plans of correction accepted and were implemented.
Deficiencies (5)
| Description |
|---|
| Resident privacy was violated when a previous licensing inspection summary was posted with attached unredacted privacy coding. |
| Resident medical evaluations were incomplete, missing resident weight and medication regimen information. |
| Staff members administering medications had not completed required annual medication administration record review for certification. |
| Two bottles of OTC medications were stored in the medication cart but were not assigned to any specific resident. |
| Medication Administration Record (MAR) was improperly maintained due to transcription errors of blood glucose test results and incorrect glucometer calibration. |
Report Facts
License Capacity: 92
Residents Served: 49
Total Daily Staff: 49
Waking Staff: 37
Residents Receiving Supplemental Security Income: 8
Residents 60 Years or Older: 46
Residents Diagnosed with Mental Illness: 21
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in medication administration training deficiency for not completing annual certification. | |
| Staff B | Named in medication administration training deficiency for not completing annual certification. |
Notice
Capacity: 92
Deficiencies: 0
Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'The Villa St. Elizabeth' following receipt of a renewal application. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and outlines the requirement for a future annual inspection to ensure compliance.
Report Facts
Maximum capacity: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 92
Deficiencies: 2
Jul 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to a resident's immediate eviction and contract violations.
Findings
The facility was found to have violated regulations by issuing an immediate eviction notice to a resident without the required 30-day written notice, contradicting PA Code 55 chapter 2600 regulations. The resident was evicted due to use of racial slurs towards a staff member, creating a harmful environment. The facility submitted a plan of correction which was later fully implemented.
Complaint Details
The complaint involved the immediate eviction of Resident 1 due to use of racial slurs towards a staff member. The eviction did not comply with the required 30-day notice protocol. The facility's plan of correction was accepted and implemented.
Deficiencies (2)
| Description |
|---|
| The home contract required immediate eviction for violations, contradicting the regulation requiring a 30-day written eviction notice. |
| Resident was given an immediate eviction notice without the required 30-day advance written notice as stipulated by regulation 2600.228b. |
Report Facts
License Capacity: 92
Residents Served: 51
Total Daily Staff: 51
Waking Staff: 38
Residents Receiving Supplemental Security Income: 18
Residents 60 Years or Older: 46
Residents Diagnosed with Mental Illness: 23
Residents Diagnosed with Intellectual Disability: 3
Inspection Report
Routine
Deficiencies: 0
May 21, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing routine licensing inspections on 05/21/2021 and 05/24/2021.
Findings
No regulatory citations were identified as a result of this inspection.
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