Inspection Report
Renewal
Census: 60
Capacity: 164
Deficiencies: 0
Sep 17, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and incident review for the facility.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on 09/17/2025, 09/18/2025, and 09/25/2025.
Report Facts
Resident Support Staff: 60
Total Daily Staff: 159
Waking Staff: 119
License Capacity: 164
Residents Served: 60
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents 60 Years or Older: 60
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Inspection Report
Census: 58
Capacity: 164
Deficiencies: 0
May 21, 2025
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 164
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Care Unit: 11
Current Hospice Residents: 5
Resident Support Staff: 0
Total Daily Staff: 88
Waking Staff: 66
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 56
Capacity: 164
Deficiencies: 4
Apr 9, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding allegations of verbal and physical abuse of a resident by staff, as well as other regulatory compliance concerns.
Findings
The investigation found multiple violations including delayed reporting of abuse incidents, failure to immediately suspend the alleged perpetrator, mistreatment of a resident, and unsanitary conditions in a resident's bathroom. Plans of correction were accepted and implemented with staff education and monitoring measures.
Complaint Details
The visit was complaint-related involving allegations of verbal and physical abuse reported by a resident against a direct care staff person. The complaint was substantiated with findings of delayed reporting, failure to suspend the alleged perpetrator, mistreatment of the resident, and unsanitary conditions.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report alleged verbal and physical abuse of a resident to the Department of Aging and Department of Human Services within required timeframes. |
| Failure to immediately suspend or place on a plan of supervision the staff person involved in the alleged abuse incident. |
| Resident was treated without dignity and respect, including aggressive physical handling and hostile verbal behavior by staff. |
| Unsanitary conditions found in a resident's private bathroom including soiled hand towel and dried urine stain on the floor. |
Report Facts
License Capacity: 164
Residents Served: 56
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 7
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 59
Capacity: 164
Deficiencies: 0
Feb 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility Schenley Gardens on 02/11/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 164
Residents Served: 59
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 58
Capacity: 164
Deficiencies: 6
Sep 24, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility on 09/24/2024, 09/25/2024, and 09/26/2024 to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including failure to conduct annual fire safety inspection and drill timely, improper calibration of a resident's glucometer, incomplete medication administration documentation, medication administration errors, discrepancies in resident assessments, and incomplete support plans. Plans of correction were accepted and implemented with proposed completion dates ranging from October 2024 to April 2025.
Deficiencies (6)
| Description |
|---|
| The most recent fire safety inspection and fire drill conducted by a fire safety expert was completed on 4/2/24; however, the previous fire safety inspection and fire drill was completed on 3/1/23, indicating a gap in annual inspection. |
| Resident #1's glucometer was not set to the current date and time. |
| Resident #2's August 2024 medication administration record (MAR) does not include the initials of staff who administered numerous medications on multiple dates/times. |
| Resident #2 was prescribed a medication to be taken twice daily but the medication was not administered on the morning of a specified date. |
| Resident #1's most recent assessment indicates independence with bladder management and toileting, conflicting with physician orders to assist with straight catheterization every 4 hours while awake and as needed for retention. |
| Resident #1's most recent support plan does not include the description and plan to meet the service need for catheterization, frequency, or responsible person. |
Report Facts
License Capacity: 164
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 5
Residents Age 60 or Older: 57
Residents with Mobility Need: 30
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 1
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Follow-Up
Census: 45
Capacity: 164
Deficiencies: 1
Jan 17, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a complaint of missing resident property, describes the corrective actions taken including audits for lockboxes, staff abuse in-service training, and ongoing resident interviews to assess abuse concerns.
Complaint Details
The visit was complaint-related due to an incident involving missing resident property. The home disputes the violation based on inaccurate dates and inconsistent resident reports, but supports audits and education.
Deficiencies (1)
| Description |
|---|
| A resident reported that 3 decorative gifts were missing from their room, indicating potential neglect or abuse. |
Report Facts
License Capacity: 164
Residents Served: 45
Residents in Secured Dementia Care Unit: 6
Hospice Residents: 8
Residents Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 17
Inspection Report
Complaint Investigation
Census: 46
Capacity: 164
Deficiencies: 0
Sep 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 09/14/2023.
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 regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 164
Residents Served: 46
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 7
Hospice Current Residents: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 16
Residents 60 Years or Older: 46
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 49
Capacity: 164
Deficiencies: 3
Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility on 03/22/2023, 03/23/2023, and 03/24/2023 to determine compliance and implementation of the submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented with deficiencies related to dietary needs, support plan revisions, and resident record content, including outdated photographs. All deficiencies had corrective plans accepted and were implemented by late April 2023.
Deficiencies (3)
| Description |
|---|
| Resident #1's special dietary needs were not met as dietary staff were unaware of the prescribed mechanical soft texture diet. |
| Resident #3's support plan had not been revised to include updated care and services as required. |
| Resident #4 and #5 had photographs in their records that were more than two years old. |
Report Facts
License Capacity: 164
Residents Served: 49
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 6
Current Hospice Residents: 8
Residents Age 60 or Older: 48
Residents with Mobility Need: 17
Inspection Report
Routine
Deficiencies: 0
Aug 15, 2022
Visit Reason
The inspection was conducted as a routine 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
Routine
Deficiencies: 0
Apr 21, 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: 164
Deficiencies: 7
Aug 19, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing requirements and address any complaints.
Findings
The inspection identified multiple deficiencies including sanitary conditions, maintenance issues such as ceiling damage and carpet stains, menu change posting failures, medication storage and prescription management issues, and equipment calibration problems. Plans of correction were accepted and implemented with follow-up audits and staff education scheduled.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for the visit being 'Renewal, Complaint'. Specific substantiation status is not stated.
Deficiencies (7)
| Description |
|---|
| Microwave in 4th floor common activity room kitchenette was splattered with a sticky, yellow substance. |
| Hole in ceiling near stove and missing ceiling tile in 4th floor activity room kitchenette with active rain water dripping causing a puddle on the floor. |
| Approximately 14 dark brown, sticky and hardened spots on carpet near resident #2's bed in resident #2's bedroom. |
| Lunch and dinner menu changes were made on numerous occasions but were not posted in a conspicuous and public place in advance of the meals. |
| A bottle containing one tablet belonging to resident #1 was unlocked, unattended and accessible on top of the medication cart in the 3rd floor hallway. |
| Medication prescribed for resident #3 was present in the medication cart but was discontinued on 1/6/21. |
| Resident #4's glucometer was not calibrated to the current date and time. |
Report Facts
License Capacity: 164
Residents Served: 49
Residents in Secured Dementia Care Unit: 8
Capacity of Secured Dementia Care Unit: 32
Current Hospice Residents: 3
Total Daily Staff: 65
Waking Staff: 49
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager of Resident Services | RN Manager | Responsible for providing education on medication regulations, completing audits, and monitoring compliance related to medication storage, prescription currentness, and glucometer calibration. |
| Housekeeping Supervisor | Cleaned microwave and carpet during inspection and responsible for ongoing cleanliness audits. |
Inspection Report
Follow-Up
Census: 50
Capacity: 164
Deficiencies: 2
Jun 2, 2021
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to medical evaluation and assessment deficiencies.
Findings
The facility was found to have fully implemented the plan of correction addressing deficiencies in resident #1's annual medical evaluation and annual assessment, including completion of missing evaluation areas and updating diagnoses. Ongoing audits and staff training were established to ensure continued compliance.
Deficiencies (2)
| Description |
|---|
| Resident #1’s annual medical evaluation dated 4/7/21 was blank in multiple evaluation areas including height, weight, temperature, medical information pertinent to diagnoses, immunizations, allergies, medication administration ability, overall health status, and cognitive functioning. |
| Resident #1’s annual assessment dated 5/28/21 did not include diagnoses indicated on the annual medical evaluation dated 4/7/21, specifically Bipolar I disorder and hyperlipidemia. |
Report Facts
License Capacity: 164
Residents Served: 50
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 3
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed letter confirming plan of correction implementation | |
| RN Manager of Resident Services | Responsible for faxing new DME, providing training, and auditing DME and RASP forms | |
| Administrator | Provided training on regulations 141a and 225 to RN Manager of Resident Services |
Inspection Report
Follow-Up
Census: 50
Capacity: 164
Deficiencies: 1
Apr 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation and included a follow-up review of the submitted plan of correction to verify its implementation.
Findings
The submitted plan of correction related to missed meals was determined to be fully implemented. The facility now stocks a second kitchen with meal substitutes available after the main kitchen closes to ensure residents who miss meals have access to adequate food.
Complaint Details
The inspection was complaint-related, focusing on the issue of missed meals and the availability of adequate food for residents who miss scheduled meal times. The plan of correction was accepted and verified as implemented.
Deficiencies (1)
| Description |
|---|
| When a resident misses a meal, food adequate to meet daily nutritional requirements was not available or offered to the resident. |
Report Facts
License Capacity: 164
Residents Served: 50
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 2
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 16
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