Inspection Reports for Twin Cedar Senior Living
364 Little Walker Rd, Shohola, PA 18458, United States, PA, 18458
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Inspection Report
Renewal
Census: 22
Capacity: 37
Deficiencies: 3
Mar 6, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Twin Cedar Senior Living.
Findings
The facility was found to have deficiencies related to fire drills and medical evaluation documentation, but the submitted plan of correction was determined to be fully implemented by the review date.
Deficiencies (3)
| Description |
|---|
| An unannounced fire drill was not held during the month of February in 2025. |
| During fire drills on 8-23-24 and 11-6-24, one resident each time did not evacuate to a designated meeting place as required. |
| The initial Medical Evaluation form for resident #1 did not indicate whether the resident is able to self-administer medications. |
Report Facts
License Capacity: 37
Residents Served: 22
Current Hospice Residents: 3
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Residents 60 Years or Older: 22
Total Daily Staff: 25
Waking Staff: 19
Residents in Fire Drill Incident: 26
Inspection Report
Follow-Up
Census: 21
Capacity: 37
Deficiencies: 2
Jun 17, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident.
Findings
The facility was found to have ongoing issues with coliform contamination in its non-public water supply, resulting in a boil water advisory and use of disposable utensils. A chlorination system was installed and the boil water advisory discontinued, with the plan of correction fully implemented.
Complaint Details
The inspection was triggered by a complaint and incident related to water quality and safety.
Deficiencies (2)
| Description |
|---|
| The facility tested positive for coliform in its non-public water supply, requiring a boil water advisory and installation of a chlorination system. |
| The facility used paper plates, plastic cups, and plastic utensils since 11/28/2024 due to the coliform contamination. |
Report Facts
License Capacity: 37
Residents Served: 21
Staffing Hours - Total Daily Staff: 24
Staffing Hours - Waking Staff: 18
Residents Age 60 or Older: 21
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 21
Capacity: 37
Deficiencies: 4
Mar 13, 2024
Visit Reason
The inspection was conducted as a renewal review of the Twin Cedar Senior Living facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/13/2024.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were identified related to resident personal equipment documentation, food storage and dating, and combustible storage hazards, all of which had corrective actions accepted and implemented by 05/02/2024.
Deficiencies (4)
| Description |
|---|
| Resident #1 and #2's Assessment Support Plans did not reflect the specific need, intended use, risks, and identification of bedside mobility devices as required. |
| Frozen uncooked pie crust and frozen pretzel rolls were stored in unsealed bags in the freezer outside the kitchen. |
| Frozen uncooked pie crust and frozen pretzel rolls in the freezer were not dated. |
| A sock was found behind the dryer in the laundry room, posing a potential fire hazard. |
Report Facts
License Capacity: 37
Residents Served: 21
Total Daily Staff: 24
Waking Staff: 18
Inspection Report
Complaint Investigation
Census: 28
Capacity: 37
Deficiencies: 0
Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 10/05/2023 and an exit conference on 10/18/2023.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or substantiated issues were found.
Report Facts
Total Daily Staff: 30
Waking Staff: 23
Resident Support Staff: 0
License Capacity: 37
Residents Served: 28
Residents 60 Years or Older: 28
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Current Hospice Residents: 0
Inspection Report
Complaint Investigation
Census: 27
Capacity: 37
Deficiencies: 2
Mar 24, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation, including an unannounced partial inspection and fire drill evacuation.
Findings
The inspection found two violations related to a fire drill evacuation incident where a resident was pushed on a rollator walker, fell, and sustained a fractured right ankle. The facility failed to provide proper equipment for safe movement and evacuation. Staff were re-educated and corrective actions were implemented.
Complaint Details
The visit was complaint-related and incident-driven. The complaint involved alleged abuse during a fire drill evacuation where a resident was pushed and injured. The violation was designated under 42b Abuse but the facility disputed the designation.
Deficiencies (2)
| Description |
|---|
| A resident was pushed on a rollator walker during a fire drill, fell, and sustained a fractured right ankle, constituting abuse under regulation 42b. |
| The home failed to provide proper physical accommodations and equipment to allow safe movement and exiting for a resident with a disability under regulation 81a. |
Report Facts
Residents Served: 27
License Capacity: 37
Staffing: 30
Waking Staff: 23
Residents with Mobility Need: 3
Residents Age 60 or Older: 27
Inspection Report
Renewal
Census: 26
Capacity: 37
Deficiencies: 7
Dec 28, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons at Twin Cedar Senior Living.
Findings
The inspection found multiple deficiencies including failure to report an incident, trash improperly stored outside, broken furniture posing hazards, improperly stored and outdated food, smoking outside designated areas, and incomplete preadmission screening documentation. All deficiencies had accepted plans of correction implemented by early February 2023.
Deficiencies (7)
| Description |
|---|
| Failure to report an unwitnessed fall with hematoma to the Department within 24 hours. |
| Trash outside the home was not kept in covered receptacles, with items found between the outside freezer and kitchen door. |
| A chair in the resident library had a broken back, creating a hazard. |
| Food was not stored in closed or sealed containers; a partially used bag of Penne pasta was unsecured. |
| Outdated or spoiled food found; two large boxes of muffin mix were undated when received. |
| Smoking outside the designated smoking room was observed with cigarette butts outside the kitchen door. |
| Preadmission screening forms were not completed within 30 days prior to admission for Resident #2. |
Report Facts
License Capacity: 37
Residents Served: 26
Staffing Hours - Total Daily Staff: 28
Staffing Hours - Waking Staff: 21
Resident Mobility Need: 2
Residents Age 60 or Older: 26
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 23
Capacity: 37
Deficiencies: 3
Feb 15, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Findings
The inspection found deficiencies related to following prescriber's orders, incomplete support plan documentation for medical/dental care, and missing resident signatures on support plans. Plans of correction were accepted and fully implemented by the facility.
Complaint Details
The visit was complaint-related and incident-driven. The plan of correction was fully implemented as of May 10, 2022.
Deficiencies (3)
| Description |
|---|
| Resident did not begin prescribed medication (Keflex) timely due to refusal of pharmacy involvement by POA. |
| Support plan did not document treatments for resident's heel wound adequately. |
| Resident participated in support plan development but did not sign the support plan. |
Report Facts
License Capacity: 37
Residents Served: 23
Staffing Hours: 25
Waking Staff: 19
Current Hospice Residents: 1
Inspection Report
Renewal
Census: 23
Capacity: 37
Deficiencies: 5
Nov 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Twin Cedar Senior Living facility to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including uncovered trash dumpsters, presence of coliform in water without alternative water supply, unlabeled and undated food in the refrigerator, locked exit doors blocking immediate egress, and missing PRN medication on the medical cart. Plans of correction were submitted and implemented with follow-up reviews confirming compliance.
Deficiencies (5)
| Description |
|---|
| Dumpster outside the home had an open lid that left garbage open to infestation. |
| Water testing showed coliform present on 10/13/2021 and 10/18/2021; no alternative water supply provided until remediation. |
| Activities refrigerator had food wrapped in foil but not labeled or dated. |
| Three exits from the home were locked by electronic keypad blocking immediate egress. |
| Resident prescribed PRN medication was not available on the medical cart at time of inspection. |
Report Facts
License Capacity: 37
Residents Served: 23
Total Daily Staff: 25
Waking Staff: 19
Hospice Residents: 1
Residents with Mobility Need: 2
Notice
Capacity: 37
Deficiencies: 0
Oct 13, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Twin Cedar Senior Living, a Personal Care Home, following receipt of the renewal application dated October 8, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. No findings or deficiencies are reported in this document.
Report Facts
Maximum licensed capacity: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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