Inspection Reports for Viva Memory Care at Dresher
1424 Dreshertown Rd, Dresher, PA 19025, PA, 19025
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Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 6
Mar 12, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident review at the facility.
Findings
The inspection identified multiple deficiencies including lack of private telephone access for residents, improper use of restraints, failure to follow medication storage and administration procedures, incomplete medication records, missed medication doses, and issues with medical evaluations for admission to the secured dementia care unit. Plans of correction were accepted and implemented by the facility.
Complaint Details
The inspection was complaint-related and included substantiation of violations related to telephone access, restraint use, medication storage and administration, medication record keeping, medication administration compliance, and medical evaluation documentation.
Deficiencies (6)
| Description |
|---|
| Residents did not have access to a telephone to make calls in privacy; staff unaware of cell phone available for private calls. |
| A resident was physically restrained during a combative incident, contrary to policy that residents shall be free from restraints. |
| Staff failed to follow safe storage and destruction procedures for controlled substances; medication wastage was not properly witnessed. |
| Medication administration records did not correctly indicate the name and initials of staff administering medication; documentation errors noted. |
| Resident did not receive prescribed medication dose at 7 PM as ordered by prescriber. |
| Resident admitted to secured dementia care unit with medical evaluation completed outside the required 60-day timeframe and included virtual visits not accepted by the facility. |
Report Facts
Residents Served: 35
License Capacity: 66
Staff Total Daily: 70
Waking Staff: 53
Current Residents in Hospice: 1
Residents Age 60 or Older: 34
Residents with Mental Illness: 1
Residents with Mobility Need: 35
Inspection Report
Renewal
Census: 32
Capacity: 66
Deficiencies: 11
Feb 27, 2025
Visit Reason
The inspection was a renewal, provisional licensing inspection conducted on February 27, 2025, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with a submitted plan of correction fully implemented. Several deficiencies were identified related to sanitary conditions, trash management, surface cleanliness, emergency telephone numbers, food storage, lint removal, menu posting, medication management, and resident assessments, all with corrective actions accepted and implemented.
Deficiencies (11)
| Description |
|---|
| Strong urine smell in various parts of the home including hallways and a resident room. |
| Trash items found on the ground near the dumpster outside the home. |
| Oblong yellow stain on carpet outside a resident room due to bleach and chemical discoloration. |
| No emergency telephone numbers posted by the rotary telephone used by a resident, except an obsolete ambulance number. |
| Unsealed tub of rainbow sherbet in the freezer with partially raised lid. |
| Thick accumulation of lint in the lint trap of a dryer used for residents' laundry. |
| Weekly menus posted without indication of the current week in the cycle. |
| Discontinued medication (1000-mg APAP tablets) found in the medication cart. |
| Loose blue and white ovular pill capsule found on the side of a medication cart in the nursing station. |
| Prescribed medications for residents #2 and #3 were not administered as ordered on 2/20/25 at 8:00 pm. |
| Initial assessment was not completed for resident #4 within 15 days of admission. |
Report Facts
License Capacity: 66
Residents Served: 32
Current Residents in Hospice: 3
Total Daily Staff: 64
Waking Staff: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
Inspection Report
Monitoring
Census: 31
Capacity: 66
Deficiencies: 4
Dec 30, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted for provisional monitoring purposes to review the facility's compliance and plan of correction implementation.
Findings
The inspection found multiple deficiencies including unlocked medications for a deceased resident, unsecured poisonous materials accessible to residents, lack of operable bedside lighting for a resident, and failure to maintain record confidentiality and medication storage procedures. The facility submitted and implemented a plan of correction with ongoing audits and staff re-education.
Deficiencies (4)
| Description |
|---|
| At least five different medications for a recently deceased resident were unlocked, unattended, and accessible behind the concierge desk. |
| A container of Dove Original Clean Antiperspirant/Deodorant Stick was unlocked, unattended, and accessible to residents, despite not all residents being assessed capable of safely using poisons. |
| A resident did not have access to a source of light that can be turned on/off at bedside. |
| A green medication delivery bin containing at least five different medications was found behind the concierge desk unlocked and unattended. |
Report Facts
License Capacity: 66
Residents Served: 31
Current Residents in Hospice: 3
Residents Age 60 or Older: 28
Residents with Mobility Need: 29
Total Daily Staff: 60
Waking Staff: 45
Inspection Report
Renewal
Census: 36
Capacity: 66
Deficiencies: 24
Mar 18, 2024
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Woodland Creek Alzheimer's Special Care Center to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including failure to retain reportable incident copies, expired food safety certification for kitchen staff, missing criminal background checks, insufficient first aid/CPR trained staff, medication storage and administration issues, incomplete medical evaluations, fire safety deficiencies, and sanitary condition concerns. Plans of correction were accepted with follow-up inspections scheduled.
Deficiencies (24)
| Description |
|---|
| The home has not retained copies of the reportable incidents between November 2023 and January 2024. |
| Staff working as cook had expired ServSafe certification and no current certified food safety manager was present. |
| Missing criminal background checks for several staff members. |
| Insufficient number of staff trained in first aid and certified in CPR; no staff meeting requirements present on some days. |
| Training records for direct care staff incomplete or missing. |
| Poisonous materials not locked and accessible to residents. |
| Trash receptacles in kitchen lacked lids. |
| Food stored on the floor in walk-in freezer. |
| Leftover food unlabeled and undated in refrigerator and freezer. |
| Food items opened and unsealed in storage areas. |
| Emergency food supply less than 3-day requirement and some expired. |
| Unannounced fire drills not documented for October 2023, December 2023, and January 2024. |
| Annual fire safety inspection and drill not conducted since May 18, 2022. |
| Fire drill records incomplete, missing exit routes and times. |
| Medical evaluation for resident missing medication list and cognitive functioning documentation. |
| Medication blister pack torn for resident. |
| PRN medications not available in the home for residents. |
| Changes in medication orders not updated in resident medication records. |
| Medication administration records missing diagnoses or purpose of medications. |
| Medication administration times not recorded accurately; medications not available but marked administered. |
| Medications not administered as prescribed due to unavailability. |
| Medication administration training records incomplete for staff. |
| Resident assessments and support plans not completed or missing required signatures. |
| Resident records missing preadmission screening and intake assessments. |
Report Facts
License Capacity: 66
Residents Served: 36
Staffing Hours: 72
Waking Staff: 54
Fine Amount: 170
Fine Amount: 102
Residents Served: 34
Total Daily Staff: 68
Waking Staff: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Serrano | Named in enforcement letter regarding fines and licensing |
Inspection Report
Follow-Up
Census: 36
Capacity: 66
Deficiencies: 5
Dec 11, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted on 12/11/2023 for complaint and monitoring purposes, including a follow-up on plan of correction submissions.
Findings
The facility was found to have multiple deficiencies related to staff qualifications, training, medication storage, and support plan documentation. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Complaint Details
The inspection was complaint-related and included monitoring. The plan of correction was submitted and reviewed with follow-up dates noted.
Deficiencies (5)
| Description |
|---|
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Resident prescription Eucerin topical cream was located in an unlocked drawer in their bathroom. |
| Resident participated in the development of support plan but the resident/assessor did not sign the support plan. |
| Resident participated in the development of support plan but the home did not document notation of inability or refusal to sign the support plan. |
Report Facts
License Capacity: 66
Residents Served: 36
Total Daily Staff: 72
Waking Staff: 54
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 36
Residents with Physical Disability: 7
Inspection Report
Follow-Up
Census: 33
Capacity: 66
Deficiencies: 5
Nov 15, 2023
Visit Reason
The inspection visit on 11/15/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to a fine.
Findings
The facility had multiple medication-related deficiencies including discontinued medications remaining in the medication cart, incorrect pharmacy labeling, incomplete medication administration records, missing staff initials on medication administration records, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Deficiencies (5)
| Description |
|---|
| Discontinued medication (Trazadone 50 mg) was found in the medication cart after discontinuation date. |
| Pharmacy label for resident #2's Quetiapine Fumarate 50 mg was inaccurate and blister pack lacked proper direction change sticker. |
| Resident #1's medication administration record did not include prescribed medications Hyoscyamine 0.125 mg and Ondansetron 4 mg. |
| Medication administration records lacked staff initials for several residents on multiple dates. |
| Resident #2 was not administered Tramadol 50 mg as prescribed on multiple dates, and medication was unavailable on some dates. |
Report Facts
License Capacity: 66
Residents Served: 33
Total Daily Staff: 66
Waking Staff: 50
Diagnosed with Mental Illness: 7
Have Mobility Need: 33
Have Physical Disability: 7
Inspection Report
Renewal
Census: 47
Capacity: 66
Deficiencies: 18
Apr 3, 2023
Visit Reason
The inspection was conducted as a renewal inspection of Woodland Creek Alzheimer's Special Care Center to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected abuse, incomplete incident reporting, missing fee schedules in resident contracts, failure to refund residents timely, neglect of resident care, unsecured poisonous materials, uncovered trash receptacles, improper refrigerator/freezer temperatures, incomplete emergency procedures, incomplete medical evaluations, missing menus posted in advance, improper medication storage, incomplete preadmission screenings and assessments, incomplete support plans, and missing signatures on support plans. Some deficiencies were repeat violations.
Deficiencies (18)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act. |
| Failure to report incidents to the Department within required timeframes. |
| Resident-home contracts did not include a fee schedule of actual amounts charged for available services for multiple residents. |
| Failure to refund residents timely for previously paid charges upon discharge. |
| Resident neglect evidenced by a resident found with three pairs of incontinence products on and failure to provide appropriate care. |
| Poisonous materials such as toothpaste and deodorants were unlocked and accessible to residents not assessed as capable of safely using them. |
| Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents. |
| Refrigerator/freezer temperatures were above required levels (freezer at 16-20°F instead of 0°F or below). |
| Emergency procedures did not include contact information for each resident’s designated person. |
| Medical evaluation of a resident did not include special health or dietary needs. |
| Weekly menus were not posted one week in advance in a conspicuous and public place. |
| Medications stored in blister packs had ripped foil backs. |
| Preadmission screening form was not completed for a resident. |
| Initial assessment was not completed within 15 days of admission for a resident. |
| Resident support plans did not document how medical/dietary needs would be met. |
| Resident participated in support plan development but did not sign the support plan. |
| Written cognitive preadmission screening was not dated for a resident admitted to the secured dementia care unit. |
| Initial support plan for a resident admitted to the secured dementia care unit was completed late. |
Report Facts
License Capacity: 66
Residents Served: 47
Staffing: 94
Waking Staff: 71
Refund Amount: 892
Refund Amount: 5000
Inspection Report
Complaint Investigation
Census: 46
Capacity: 66
Deficiencies: 5
Jan 12, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Woodland Creek Alzheimer's Special Care Center to review compliance with regulations and assess the submitted plan of correction.
Findings
Multiple deficiencies were identified including lack of overnight medication administration staff, absence of CPR-certified staff on certain dates, incomplete annual medical evaluations, failure to follow prescriber's orders, and missing incident reports in resident records. Plans of correction were submitted and later determined to be fully implemented.
Complaint Details
The inspection was complaint-driven and incident-related, with follow-up on the submitted plan of correction. The plan of correction was initially not accepted for some deficiencies but later accepted and fully implemented.
Deficiencies (5)
| Description |
|---|
| No Med Tech or Nurse present overnight to administer PRN medications on multiple dates. |
| No staff certified in first aid and CPR present overnight on multiple dates. |
| Resident's annual medical evaluation was not completed timely. |
| Medication administered outside the effective dates of the prescriber's order. |
| Resident records missing incident reports dated on various occasions. |
Report Facts
License Capacity: 66
Residents Served: 46
Current Residents in Hospice: 4
Dates without Med Tech or Nurse overnight: 10
Dates without CPR certified staff overnight: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health Services Director (HSD) | Named as responsible for education, audits, and ensuring compliance with medication administration, CPR certification, medical evaluations, and record keeping. | |
| Nursing Staff | Educated on regulations and responsible for following prescriber orders and documentation. | |
| Executive Director (ED) | Responsible for ensuring resident chart audits and report management. |
Inspection Report
Follow-Up
Census: 38
Capacity: 66
Deficiencies: 2
Nov 15, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident involving aggressive behavior by a resident, to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing incidents of resident aggression and abuse. The report details multiple aggressive incidents involving Resident #1, including physical aggression towards other residents and staff, with no injuries reported. The facility has taken steps including supervision, family and physician notification, and staff reeducation on abuse and safe management techniques.
Deficiencies (2)
| Description |
|---|
| Resident #1 became physically aggressive with other residents, including grabbing and squeezing, requiring staff intervention and hospital evaluation. |
| The facility failed to use positive interventions to modify or eliminate aggressive behavior of Resident #1 during early morning hours before 8:00 a.m. when 1:1 supervision was not present. |
Report Facts
License Capacity: 66
Residents Served: 38
Total Daily Staff: 76
Waking Staff: 57
Inspection Report
Census: 35
Capacity: 66
Deficiencies: 0
Jul 21, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 35
License Capacity: 66
Staffing Hours: 70
Waking Staff: 53
Inspection Report
Renewal
Census: 37
Capacity: 66
Deficiencies: 18
Apr 29, 2022
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/29/2022 and 05/02/2022 to review compliance of Woodland Creek Alzheimer's Special Care Center.
Findings
The inspection identified multiple deficiencies including missing resident contract signatures, incomplete medical evaluations, medication administration errors, failure to conduct monthly fire drills, unlocked poisonous materials accessible to residents, and incomplete criminal background checks for staff. Plans of correction were accepted for all deficiencies with specified completion dates.
Deficiencies (18)
| Description |
|---|
| Resident-home contract for resident #1 was not signed by the resident with no notation of opportunity to sign. |
| Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Criminal background check was not obtained for Staff A at time of hire. |
| Resident #2's bed was equipped with an uncovered enabler. |
| An unannounced fire drill was not held during December 2021; fire drill record lacked contact with Regional Director. |
| No fire drill observed by a fire safety expert in 2021; last observed drill was on 03/16/2022. |
| Resident #3's medical evaluation indicated 'None' for special health and dietary needs despite secured dementia care requirement. |
| Resident #4's medical evaluation did not indicate ability to self-administer medications. |
| Expired medication prescribed for resident #3 was found in the home's medication cart. |
| Medication prescribed as needed for resident #4 was not available in the home on 05/02/2022. |
| No documentation regarding disposal of refused medication doses for resident #4 on 04/23/2022 and 04/25/2022. |
| Medication administration record for resident #1 lacked initials of staff administering medication on 04/08 and 04/29. |
| Failure to notify prescriber of resident #4's refusal to take scheduled medication on 04/23/2022. |
| Staff person B had incomplete medication administration observations in 2021 but administered medications in 2022. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #5 was prescribed medication as a chemical restraint for agitation; medication was administered on multiple days. |
| Resident #3's cognitive prescreening date was written over without proper notation. |
| Poisonous materials including antibacterial soap and toothpaste were unlocked and accessible in resident rooms without assessment of residents' ability to safely use or avoid poisons. |
Report Facts
License Capacity: 66
Residents Served: 37
Total Daily Staff: 74
Waking Staff: 56
Current Hospice Residents: 4
Inspection Report
Complaint Investigation
Census: 38
Capacity: 66
Deficiencies: 2
Apr 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/20/2022.
Findings
The facility was found to have deficiencies related to support plan needs elements and record entries legibility for resident #1. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related and the plan of correction was submitted and accepted. The complaint deficiencies involved support plan and record entry documentation issues for resident #1.
Deficiencies (2)
| Description |
|---|
| The support plan for resident #1 does not address Ambulating. |
| On resident #1's admission support plan, the date assessment finalized and the date support plan finalized were written over without proper notation. |
Report Facts
License Capacity: 66
Residents Served: 38
Total Daily Staff: 76
Waking Staff: 57
Follow-Up Date: May 13, 2022
Inspection Report
Follow-Up
Census: 33
Capacity: 66
Deficiencies: 8
Mar 17, 2022
Visit Reason
The inspection visit on 03/17/2022 was a partial, unannounced follow-up inspection triggered by an incident at the facility to review the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to abuse, restraints, staff training, menu changes, resident support plans, and documentation compliance. The plan of correction was accepted and fully implemented by the follow-up date.
Deficiencies (8)
| Description |
|---|
| Resident #1 was physically restrained by staff member B grabbing both wrists, causing a small tear to the resident's wrist. |
| Staff person A and B did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, abuse reporting, and incident reporting. |
| Ancillary staff person A did not have a general orientation to specific job functions prior to working in that capacity. |
| Menu substitution was made without prior notice to residents; French Toast with Sausage Patties was replaced by Waffles with pork roll without notice. |
| Resident #2 admitted to secured dementia care unit without documentation of no objection from resident or designated person. |
| Resident #1's initial support plan was completed late; Resident #2's initial support plan was not completed. |
| Resident #2's support plan was not revised to reflect a change in condition related to toileting needs. |
| Resident #2's support plan was developed without involvement of the resident or designated person. |
Report Facts
License Capacity: 66
Residents Served: 33
Current Hospice Residents: 3
Total Daily Staff: 66
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Named in findings related to physical restraint and abuse of resident #1 | |
| Staff person A | Named in findings related to incomplete training within 40 scheduled work hours | |
| Staff person B | Named in findings related to incomplete training within 40 scheduled work hours and termination | |
| Ancillary staff person A | Named in findings related to lack of orientation to job functions |
Inspection Report
Renewal
Census: 22
Capacity: 66
Deficiencies: 9
May 5, 2021
Visit Reason
The inspection was a renewal inspection conducted on 05/05/2021 and 05/07/2021 to review compliance with licensing requirements for Woodland Creek Alzheimer's Special Care Center.
Findings
The inspection identified multiple deficiencies related to medication errors, failure to report incidents, unsafe storage of poisonous materials, exterior hazards, improper documentation of medication administration, and incomplete preadmission screenings. The facility submitted a plan of correction which was determined to be fully implemented by the follow-up date.
Deficiencies (9)
| Description |
|---|
| Several medication errors were discovered during a resident medication and administration audit, and the home's management team was not made aware of these errors or submitted incident reports to the Department. |
| Poisonous materials such as Dermasil Moisturizing Body Wash, Colgate Toothpaste, and Polident Antibacterial Denture cleaner were unlocked, unattended, and accessible to residents assessed as not capable of recognizing and using poisons safely. |
| Storm drains in the North Courtyard presented a tripping hazard as they were not level with the ground and the covers were not secured. |
| Glucometer readings for resident #2 were not documented on the MAR or glucometer log, and the glucometer time was incorrect. |
| Resident #2's medication (Miralax) was not available for administration on 05/07/21 but was marked as administered on the MAR. |
| Medication errors were not reported to the resident, the resident’s designated person, or the prescriber. |
| There was no documentation of medication errors and prescriber responses in the resident's record. |
| The home did not have a system to identify and document medication errors and patterns of errors. |
| Written cognitive preadmission screenings for residents admitted to the Secure Dementia Care Unit were not completed within 72 hours prior to admission. |
Report Facts
License Capacity: 66
Residents Served: 22
Total Daily Staff: 44
Waking Staff: 33
Medication Errors: 5
Notice
Capacity: 66
Deficiencies: 0
Apr 16, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Woodland Creek Alzheimer's Special Care Center, indicating that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license following the renewal application and advises that an inspection will occur within the next year.
Report Facts
Total licensed capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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