Inspection Reports for
Trillium Place
1520 HARRISBURG PIKE,, LANCASTER, PA, 17601
Back to Facility Profile22 Reports
Inspection Report — Apr 21, 2026
Follow-Up
Date: Apr 21, 2026
Visit Reason
The inspection was conducted as a renewal and incident review to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have an expired vehicle inspection sticker on a bus used for resident transport and multiple medication administration errors involving failure to follow prescriber orders. Corrective actions were implemented and verified during the follow-up inspection.
Citations (2)
55 Pa. Code § 2600.171(c) The facility bus used to transport residents had an expired Pennsylvania inspection sticker, and documentation of a current inspection was not available at the time of review.
2600.187(d) Failure to consistently follow prescriber orders for medication administration was identified for multiple residents, including missed doses and incorrect timing.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 16
Medication incidents: 4
Inspection Report — Jan 22, 2025
Renewal
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license to assess compliance with regulatory requirements.
Findings
The report indicates that the submitted plan of correction was fully implemented and compliance must be maintained. Several deficiencies were identified and corrected, including issues with refunds, bathroom ventilation, refrigerator temperatures, self-administration assessments, and following prescriber's orders.
Citations (5)
Refund due to resident for early move-out was not processed timely.
Ventilation fans in communal bathrooms were inoperable and there were no windows for ventilation.
Refrigerator temperatures exceeded required limits for food safety on multiple occasions.
Residents were not assessed by a qualified professional regarding ability to self-administer medications.
Medications were not administered according to prescriber's orders for multiple residents.
Report Facts
Residents Served: 65
Refund Amount: 2605.21
Staffing Hours: 86
Waking Staff: 65
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 1
Residents with Mobility Need: 21
Residents 60 Years or Older: 65
Residents Diagnosed with Mental Illness: 1
Inspection Report — Mar 19, 2024
Renewal
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including uncovered trash receptacles inside and outside the facility, lack of thermometers in refrigerators and freezers, missing fire extinguisher locations on evacuation diagrams, overdue fire drills during sleeping hours, unsecured medications in a resident's room, and incomplete pharmacy labeling on medication packets. Plans of correction were accepted and implemented by mid-April 2024.
Citations (9)
Two full, uncovered, unattended trash cans in the dining rooms of the secured dementia care unit.
Two out of three outside dumpsters were uncovered.
Resident 2 does not have access to a source of light that can be turned on/off at bedside.
Boxes containing food items were stored on the floor in the walk-in refrigerator and freezer.
No thermometers in the 3rd floor freezer and refrigerators in the dining room and kitchenette on the 5th floor.
Emergency evacuation diagram near room 511 does not include the location of fire extinguishers.
The last fire drill during sleeping hours was conducted on 8/10/23, overdue for the required semi-annual drill.
Several unlocked, unattended medications found in Resident 1's bedroom.
Pharmacy labels on medication packets for multiple residents do not include prescribed dosage and administration instructions.
Report Facts
Residents served: 48
Staff total daily: 64
Waking staff: 48
Secured Dementia Care Unit residents served: 16
Hospice current residents: 1
Residents aged 60 or older: 48
Residents diagnosed with mental illness: 1
Residents with mobility need: 16
Inspection Report — May 30, 2023
Date: May 30, 2023
Visit Reason
The inspection was conducted due to an incident, as part of a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Total Daily Staff: 70
Waking Staff: 53
Residents Served: 54
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 1
Residents Age 60 or Older: 54
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Inspection Report — Nov 30, 2022
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason stated as 'Incident'.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Total Daily Staff: 68
Waking Staff: 51
Residents Served: 55
Secured Dementia Care Unit Residents Served: 13
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report — Oct 13, 2022
Plan of Correction
Date: Oct 13, 2022
Visit Reason
The visit was conducted to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Notice — Jan 22, 2021
Date: Jan 22, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Mennonite Home Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Bashore-Steury | Director of Personal Care | Recipient of the renewal notification letter |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signer of the renewal notification letter |
Notice — Feb 7, 2020
Date: Feb 7, 2020
Visit Reason
The document serves as a notification of approval for a revised license capacity reduction request for the Mennonite Home Personal Care Home facility.
Findings
The Department approved a reduction in licensed capacity from 150 to 125 residents. The expiration date of the license remains unchanged.
Report Facts
Inspection Report — Oct 25, 2019
Renewal
Date: Oct 25, 2019
Visit Reason
The document is a renewal application and license issuance for Mennonite Home to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It is a license renewal notice with an enclosed license certificate.
Report Facts
Inspection Report — Sep 23, 2019
Annual Inspection
Date: Sep 23, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an annual inspection of the Mennonite Home on September 23 and 24, 2019 to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual inspection.
Inspection Report — Dec 26, 2018
Complaint Investigation
Date: Dec 26, 2018
Visit Reason
The inspection was conducted as a result of an incident complaint at the Mennonite Home on December 26, 2018.
Complaint Details
The inspection was triggered by an incident complaint. Specific substantiation status is not stated.
Findings
The inspection found a violation of 55 Pa.Code Chapter 2600 related to the Resident Assessment and Support Plan for Resident 1, which had not been updated to include information about hallucinations and dementia-related therapy. A plan of correction was approved to address this issue.
Citations (1)
55 Pa.Code 2600.227(c) - The Resident Assessment and Support Plan for Resident 1 was not updated to include information about hallucinations and dementia-related therapy. The plan must be revised within 30 days after the annual assessment or changes in the resident's needs.
Report Facts
Number of Residents Served: 98
Number of Residents Served in Secured Dementia Care Unit: 11
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Heemer | Department representative on-site during inspection | |
| Joshua Bashore-Steury | Director of Personal Care | Administrator named in the report |
Notice — Nov 26, 2018
Date: Nov 26, 2018
Visit Reason
The document is a response to a waiver request for qualifications of direct care staff persons at Mennonite Home.
Findings
The Department determined that a waiver is not needed as the staff member's educational documentation meets the requirements to serve as a direct care staff person.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver response letter |
Inspection Report — Oct 26, 2018
Renewal
Date: Oct 26, 2018
Visit Reason
The document is a renewal application and license issuance for The Mennonite Home Personal Care Home, confirming the facility's authorization to operate and stating the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and outlines the regulatory requirement for future inspections.
Report Facts
Inspection Report — Sep 5, 2018
Renewal
Date: Sep 5, 2018
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on September 5 and 6, 2018, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection identified violations related to staff training in medication self-administration and fire safety, exit door security in the secured dementia care unit, and incomplete cognitive pre-admission screening documentation for residents. Plans of correction were submitted addressing each violation with timelines for completion.
Citations (4)
55 Pa.Code §2600.65(f): Direct Care Staff Person B did not receive training in medication self-administration during training year 2017.
55 Pa.Code §2600.65(g): Ancillary Staff Person A did not receive fire safety training by a fire safety expert during training year 2017.
55 Pa.Code §2600.121(a): Exit doors at secured dementia care unit bedrooms are not programmed to unlock with visitor key fobs.
55 Pa.Code §2600.231(c): Resident #1 and Resident #2 had incomplete cognitive pre-admission screening documentation within 72 hours prior to admission to the secured dementia care unit.
Report Facts
Number of Residents Served: 95
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua F. Bashore-Steury | Director of Personal Care | Named as Administrator and Legal Entity Representative signing plans of correction. |
| Kellie Comstock | Department representative conducting the inspection. | |
| Jason McCloskey | Department representative conducting the inspection. |
Inspection Report — Nov 29, 2017
Renewal
Date: Nov 29, 2017
Visit Reason
The inspection was a licensing inspection conducted by the Department of Human Services on November 29, 2017, related to compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes. The visit was unannounced and triggered by an incident.
Findings
One violation was found regarding the failure to complete a resident's initial assessment within 15 days of admission. A plan of correction was submitted to address this deficiency.
Citations (1)
55 Pa.Code 2600.225(a) requires a written initial assessment within 15 days of admission. Resident #1's initial assessment was not completed within the required timeframe.
Report Facts
Number of Residents Served: 104
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 7
Number of Residents Age 60 or Older: 104
Number of Residents with Supplemental Security Income: 3
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 30
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua F. Bashore-Steury | Director of Personal Care | Administrator named in report and plan of correction |
| Kellie Cargile | Department Representative conducting inspection |
Notice — Oct 23, 2017
Date: Oct 23, 2017
Visit Reason
The document serves as a renewal notification and license issuance for The Mennonite Home Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
No inspection findings are reported. The letter advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Aug 30, 2017
Renewal
Date: Aug 30, 2017
Visit Reason
The inspection was conducted as part of the annual licensing renewal of the Mennonite Home Personal Care Home on August 30 and 31, 2017.
Findings
The inspection identified violations related to failure to report an incident, failure to conduct required fire drills, and improper storage of discontinued medications. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
Regulation 55 Pa.Code §2600.16(c): The home failed to report an incident involving a resident who received twelve stitches after a fall to the Department within 24 hours as required.
Regulation 55 Pa.Code §2600.132(e): The home had not performed a sleeping hours fire drill since 1/26/17 as required every six months.
Regulation 55 Pa.Code §2600.183(d): Discontinued medications, including prescribed Melatonin and Artificial Tears, were still stored in the medication cart on 8/23/17.
Report Facts
Number of Residents Served: 116
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 7
Number of Residents Age 60 or Older: 116
Number of Residents with Mental Illness: 2
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 22
Number of Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Josh Bashore-Steury | Administrator, PLHA, LSW | Named in plan of correction signatures and violation responses |
| Joel Bashore-Steury | PLHA, LSW | Named in plan of correction signatures and violation responses |
Notice — May 4, 2017
Date: May 4, 2017
Visit Reason
This letter responds to a request for a waiver of Pennsylvania Code Chapter 2600 requirements related to qualifications for direct care staff persons at Mennonite Home.
Findings
The waiver request is denied as not needed because documentation confirms the individual has a Commonwealth Secondary School Diploma and meets educational qualifications for direct care staff.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver response letter. |
Notice — Feb 24, 2017
Date: Feb 24, 2017
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under Pennsylvania Code Chapter 2600 for a personal care home.
Findings
The waiver request was returned for additional information because the staff member received a diploma from a non-accredited high school and does not meet the requirements. Alternatives to meet the education requirements were provided.
Report Facts
Pa.Code Chapter: 2600
Waiver requested: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver response letter |
Notice — Dec 14, 2016
Date: Dec 14, 2016
Visit Reason
The document serves as a response to a request for a waiver of Pennsylvania Code Chapter 2600 requirements relating to qualifications for direct care staff persons at The Mennonite Home.
Findings
The Department of Human Services granted the requested waiver under the authority of 55 Pa.Code § 2600.19, determining that the non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Notice — Dec 8, 2016
Date: Dec 8, 2016
Visit Reason
The document serves as a renewal notification for the Personal Care Home license of The Mennonite Home, confirming receipt of the renewal application and outlining the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative notice confirming license renewal and inspection requirements.
Report Facts
Inspection Report — Sep 14, 2016
Renewal
Date: Sep 14, 2016
Visit Reason
The inspection was conducted as part of the annual licensing renewal for The Mennonite Home on September 14 and 15, 2016.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found and specified in the enclosed License Inspection Summary. The facility was cited for failing to refund a resident's estate within 30 days following the resident's death.
Citations (1)
55 Pa.Code 2600.28(e) requires the administrator to refund the remainder of a deceased resident's estate within 30 days. The home failed to refund the resident's estate after the resident's death on 4/21/16.
Report Facts
Number of Residents Served: 104
Number of Residents Served in Secured Dementia Care Unit: 14
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 2
Residents Age 60 or Older: 104
Residents Receiving Supplemental Security Income: 3
Residents with Mental Illness: 1
Residents with Intellectual Disability: 1
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Sauder | Administrator | Named as administrator of the facility |
| John F. Osborn | Legal Entity Representative | Signed plan of correction |
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