Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 42
Capacity: 77
Deficiencies: 4
Jul 24, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following a complaint and interim review.
Findings
The facility was found to have fully implemented the plan of correction related to medication management and fire safety deficiencies. Specific deficiencies included non-fire resistant chair cushions in the smoking area, medication errors involving discontinued medications, missing PRN medications, and incomplete medication records, all of which were corrected with new procedures and staff retraining.
Complaint Details
The inspection was complaint-related and interim in nature, with follow-up to verify correction of cited deficiencies.
Deficiencies (4)
| Description |
|---|
| The home’s designated smoking area contained chair cushions without fire resistant tags. |
| Discontinued medications were found in the home's medication cart due to pharmacy and staff errors. |
| A prescribed PRN medication (Acetaminophen) was not available in the medication cart. |
| A prescribed sublingual medication was administered but not included on the resident's medication administration record. |
Report Facts
License Capacity: 77
Residents Served: 42
Current Hospice Residents: 6
Total Daily Staff: 44
Waking Staff: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Lendzinski | RN Nurse | Involved in investigation and implementation of new medication procedures |
Inspection Report
Renewal
Census: 46
Capacity: 77
Deficiencies: 29
May 14, 2025
Visit Reason
The inspection was a renewal visit conducted on 05/14/2025 to review compliance with licensing regulations at WALDEN III SENIOR LIVING COMMUNITY.
Findings
The inspection identified multiple deficiencies including issues with contract signatures, hospice care documentation, criminal background checks, staff training, sanitary conditions, fire safety drills, medication administration, and resident records management. Plans of correction were accepted and implemented with follow-up audits scheduled.
Deficiencies (29)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Resident 3 was not evacuated during fire drills due to lack of physician certification that the resident is actively dying. |
| Resident 3 lacked written informed consent from resident or POA not to evacuate during fire drills. |
| No staff member informed resident 3 during fire drills that the alarm was a drill and resident was not to evacuate. |
| Criminal background checks for staff persons B and C were not completed as required. |
| Direct care staff person C did not complete required initial direct care training before providing unsupervised ADL services. |
| Staff person D did not receive training in the Older Adult Protective Services Act during the 2024 training year. |
| A spray bottle labeled only 'Fabuloso' was found not in its original container. |
| Feces were found on a toilet seat in a shower room and a strong urine odor was detected in a resident's room. |
| Two uncovered trash cans were found in shared shower rooms. |
| Two exterior garbage cans outside the kitchen exit door lacked lids. |
| Emergency telephone numbers were not posted by the landline telephone in room 132. |
| An unlabeled used bar of soap was found in a shared bathroom. |
| An unlabeled, undated container of cut up strawberries was found in the kitchen refrigerator. |
| No thermometer was present in the kitchen refrigerator. |
| Lint accumulation was found in the lint trap of the laundry dryer. |
| A cardboard box and bag of garbage blocked an exit door near room 142. |
| Combustible materials (dryer sheet and wash clothes) were found behind the dryer on the exhaust vent. |
| Fire drills were not held during October, November, and December 2024. |
| Fire drill record for 1/10/2025 did not document why resident #3 was not evacuated. |
| Fire drill conducted at 6:00 am was not during sleeping hours as required. |
| Resident #3 was not evacuated to a designated meeting place during multiple fire drills. |
| Resident #4's most recent medical evaluation did not include the resident's pulse. |
| A paper cup full of ashes and cigarette butts were found on the front porch near room 129. |
| Staff person D administered medications using a tray with multiple medication cups, violating proper medication administration procedures. |
| Resident #7 had an order for Nystatin powder not documented on the Medication Administration Record. |
| Resident #5's assessment did not indicate physical therapy that began prior to the annual assessment. |
| Resident #6's support plan did not reflect the need, use, or identification of a bedside mobility device. |
| Resident records were destroyed without maintaining a required log of the destroyed records. |
Report Facts
License Capacity: 77
Residents Served: 46
Hospice Residents: 5
Residents Age 60 or Older: 46
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 2
Staffing Hours - Resident Support Staff: 13
Staffing Hours - Total Daily Staff: 61
Staffing Hours - Waking Staff: 46
Deficiencies Cited: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person D | Named in medication administration violation and retraining | |
| Staff person C | Named in criminal background check and initial direct care training violations | |
| Staff person B | Named in criminal background check violation | |
| Resident #3 POA | Named in hospice care informed consent violation | |
| Administrator | Named in multiple findings and corrective actions | |
| Assistant Administrator | Named in multiple findings and corrective actions |
Inspection Report
Follow-Up
Census: 40
Capacity: 77
Deficiencies: 2
Mar 14, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident, followed by a plan of correction submission and document review to verify compliance.
Findings
The facility was found to have deficiencies related to missing resident height and weight on initial medical evaluations and failure to update a resident support plan after an elopement incident. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The visit was complaint-related due to an incident where a resident eloped from the home and was found approximately 3 hours later in a nearby wooded area. The resident support plan was not updated after this incident to address the increased supervision needs. The complaint was substantiated as deficiencies were found.
Deficiencies (2)
| Description |
|---|
| The initial Medical Evaluation for residents was missing the resident’s height and weight. |
| Resident support plan was not updated after an elopement incident to address increased need for close supervision. |
Report Facts
License Capacity: 77
Residents Served: 40
Current Hospice Residents: 5
Residents Age 60 or Older: 40
Residents with Mobility Need: 3
Total Daily Staff: 43
Waking Staff: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Med Tech Supervisor | Went to residents' rooms to weigh and measure residents and recorded readings on the DME | |
| Administrator | Audited all existing resident DMEs and RASPs to ensure compliance and prevent future omissions |
Inspection Report
Follow-Up
Census: 42
Capacity: 77
Deficiencies: 4
Sep 11, 2024
Visit Reason
The inspection visit on 09/11/2024 was a partial, unannounced follow-up inspection triggered by a complaint and interim review to verify the implementation of a previously submitted plan of correction.
Findings
The inspection found that the facility had implemented corrective actions for multiple deficiencies including missing window screens, loose handrails, incomplete fire department notification, and medication storage and documentation errors. All plans of correction were accepted and implemented by 10/16/2024.
Complaint Details
The visit was complaint-related and interim in nature, with follow-up on a plan of correction submitted previously. The plan of correction was determined to be fully implemented.
Deficiencies (4)
| Description |
|---|
| 12 windows in the breezeway were missing screens. |
| The exterior handrail near the basement exit was very loose and not securely fastened. |
| The notice letter to the local fire department did not include capacity or building description and mentioned outdated resident evacuation assistance details. |
| Medication storage procedures were deficient; a medication administration record error occurred due to incorrect glucometer reading documentation. |
Report Facts
License Capacity: 77
Residents Served: 42
Current Hospice Residents: 12
Total Daily Staff: 43
Waking Staff: 32
Windows missing screens: 12
Inspection Report
Renewal
Census: 43
Capacity: 77
Deficiencies: 21
Jul 9, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post required documents, incomplete staff training, fire safety issues, medication management errors, and documentation inaccuracies. Plans of correction were accepted and many were implemented by October 2024.
Deficiencies (21)
| Description |
|---|
| The home did not post a copy of the Department of Public Welfare Chapter 2600 Personal Care Homes regulation book in a conspicuous and public place. |
| The home did not have documentation that an annual quality management plan review had taken place in the last 12 months. |
| Staff person A did not complete their first day orientation on fire safety and emergency preparedness topics. |
| Staff person A did not complete orientation on Emergency Medical Plan within 40 scheduled work hours. |
| The home had no verification that Direct care staff person B completed and passed the Department-approved direct care training course and competency test. |
| Direct care staff members C and D did not receive required training in medication self-administration, care for residents with dementia, and other required topics during 2023. |
| Staff person B did not receive training in emergency preparedness procedures, resident rights, and OAPSA during 2023. |
| Required emergency telephone numbers were not posted on or near the landline phone in room #115. |
| Six windows in the hallway leading to rooms 140 through 150 were open but did not have screens. |
| The basement staircase leading to the side exit door did not have a handrail; a step down at the exit door also lacked a handrail or handle. |
| A carpet pad was noted obstructing the egress route on a landing at the top of the basement stairs; the exit door next to the bird cage would not open without excessive force. |
| The home was unable to provide verification of the required Notice to the local Fire Department. |
| A fire drill record was not maintained for drills held from June 2023 to December 2023. |
| The home did not have a fire safety inspection conducted by a fire safety expert within the past 12 months. |
| The evacuation certification time expired and the home did not meet the required evacuation time during 2024 fire drills. |
| Resident #1 was not assessed to self-administer medications; topical prescription was found on the resident’s nightstand without proper assessment. |
| Resident #2 stored medications in unlocked dresser drawers and did not lock their door when leaving the room. |
| Resident #3 had an insulin pen with a date that rubbed off and could not be verified by staff. |
| Medication administration records for Residents #3 and #10 showed blood glucose readings without corresponding glucometer logs; narcotic counts for Residents #5 and #6 were unaccounted for, indicating possible medication mismanagement. |
| Resident #4’s medication record did not match the medication label regarding dosage strength. |
| Residents #7, #8, and #9 utilized bed enabler bars but their charts did not reflect the specific need, intended use, risks, or device details as required. |
Report Facts
Residents Served: 43
License Capacity: 77
Staffing Hours: 44
Waking Staff: 33
Current Residents in Hospice: 4
Residents Age 60 or Older: 43
Residents with Mobility Need: 1
Number of Windows without Screens: 6
Number of Windows Measured for Screens: 10
Number of Additional Windows Ordered for Screens: 2
Fire Drill Missing Record Period: 7
Evacuation Time: 7.67
Standard Evacuation Time: 2.5
Fire Drill Evacuation Time 2024: 4.22
Missing Narcotic Doses: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to incomplete orientation and abandonment of position on 07/10/2024 | |
| Staff Person B | Named in findings related to incomplete direct care training and annual training topics | |
| Staff Person C | Named in findings related to incomplete annual training topics | |
| Staff Person D | Named in findings related to incomplete annual training topics | |
| Staff Person #1 | Med Tech | Abandoned position on 07/11/2024; involved in medication mismanagement investigation |
| Med Tech Supervisor | Involved in medication management and training, internal investigations, and audits | |
| Administrator | Responsible for oversight, corrective actions, training, and communication with authorities | |
| Train the Trainer RN | Trainer | Conducted retraining of med techs on medication administration and charting |
| Fire Chief | Conducted supervised fire drills and provided fire evacuation time letters | |
| Officer | Conducted police investigation into medication discrepancies |
Inspection Report
Follow-Up
Census: 46
Capacity: 77
Deficiencies: 4
Apr 24, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to kitchen cleanliness, food labeling, refrigeration temperatures, and outdated food. The submitted plan of correction was determined to be fully implemented by the date of the follow-up.
Complaint Details
The inspection was complaint-driven, as indicated by the reason stated in the inspection information section.
Deficiencies (4)
| Description |
|---|
| The stove in the kitchen was crusted with food on the burners and had a layer of grease on the back, posing a fire hazard. |
| Open bags of frozen sausages and stuffed shells in freezers were unlabeled and undated; open jugs of iced tea and lemonade were undated. |
| The refrigerator portion of the kitchen freezer/refrigerator unit did not have a thermometer. |
| Heinze Ketchup and other condiments were left on dining room tables beyond recommended times without proper refrigeration or dating. |
Report Facts
Residents Served: 46
License Capacity: 77
Current Hospice Residents: 5
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Complaint Investigation
Census: 52
Capacity: 77
Deficiencies: 0
Oct 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation at WALDEN III SENIOR LIVING COMMUNITY on 10/20/2023.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial licensing inspection.
Complaint Details
The inspection was triggered by a complaint; however, no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 77
Residents Served: 52
Current Hospice Residents: 1
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 55
Capacity: 77
Deficiencies: 15
Jun 29, 2023
Visit Reason
The inspection was conducted as a renewal review of the Walden III Senior Living Community facility to assess compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies including issues with record confidentiality, compliance with laws, direct care staff qualifications and training, resident personal equipment safety, trash management, unobstructed egress, and medication management. All deficiencies had plans of correction accepted and were implemented by the facility.
Deficiencies (15)
| Description |
|---|
| Privacy codes were posted with the violation report in a publicly accessible binder. |
| The home did not have an influenza poster issued by the Pennsylvania Department of Health posted. |
| Direct care staff person 'A' did not have documentation of required education such as high school diploma, CNA certificate, or GED. |
| The home did not document meeting required direct care staffing hours on multiple dates in June 2023. |
| The home did not document meeting required waking hours of direct care staffing on multiple dates in June 2023. |
| Ancillary staff person 'B' did not receive required first day orientation staff training; direct care staff person 'C' lacked documentation of first day orientation. |
| Ancillary staff person 'B' did not receive required first 40-hours staff training; direct care staff person 'C' lacked documentation of first 40 hours training. |
| Ancillary staff person 'B' did not have documentation of orientation to ancillary job duties. |
| Direct care staff person 'A' did not have record of passing the Personal Care Direct Care Competency Exam. |
| Direct care staff person 'C' did not receive required annual training in safe management techniques for 2022. |
| Direct care staff persons 'C' and 'D' did not receive required annual training in emergency preparedness, Adult Protective Services Act, and falls prevention. |
| Resident bed rails lacked covers, creating entrapment hazards. |
| Trash dumpsters lids and sliding doors were open; outdoor trash can lacked a lid. |
| Emergency exit door in main dining area was obstructed by a blanket. |
| First aid kit contained expired antibacterial cream. |
Report Facts
Residents Served: 55
License Capacity: 77
Direct Care Staffing Hours Required: 52
Direct Care Staffing Hours Found: 39
Direct Care Staffing Hours Found: 45
Direct Care Staffing Hours Found: 45.5
Direct Care Waking Hours Required: 39.5
Direct Care Waking Hours Found: 22.5
Direct Care Waking Hours Found: 30
Direct Care Waking Hours Found: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct care staff person / Overnight housekeeping staff | Named in deficiencies related to education documentation, competency exam, and training completion |
| Staff person B | Ancillary staff person / Maintenance man | Named in deficiencies related to orientation, 40-hour training, and ancillary job duties |
| Staff person C | Direct care staff person | Named in deficiencies related to orientation, 40-hour training, annual training, and safe management techniques |
| Staff person D | Direct care staff person | Named in deficiency related to annual training in falls prevention |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 77
Deficiencies: 4
Feb 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with medication handling and administration regulations at Walden III Senior Living Community.
Findings
The inspection found multiple deficiencies related to improper medication storage, labeling, narcotic counts, and failure to follow prescriber's orders. The facility submitted a plan of correction which was fully implemented by the time of the follow-up.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state substantiation status but notes multiple medication-related violations.
Deficiencies (4)
| Description |
|---|
| Prescription medications were removed from original containers and repackaged into blister packs, violating regulation 2600.183.a. |
| Resident medications did not have pharmacy labels attached, violating regulation 2600.184.a. |
| Narcotic counts were not consistently completed and documented at the start and end of each shift, violating regulation 2600.185.a. |
| Failure to follow prescriber's orders regarding medication administration based on systolic blood pressure parameters, violating regulation 2600.187.d. |
Report Facts
Licensed capacity: 77
Residents served: 44
Resident Support Staff: 46
Total Daily Staff: 92
Waking Staff: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in multiple findings related to medication handling and narcotic counts | |
| Med Tech Supervisor | Named in multiple findings related to medication handling and narcotic counts | |
| Lead Tech | Involved in conducting weekly medication surveys and retraining staff |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 77
Deficiencies: 2
Jan 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation to address concerns related to sanitary conditions and support plan documentation at Walden III Senior Living Community.
Findings
The inspection found violations related to unsanitary conditions including blood stains, live bugs, strong odors, and soiled bedding in residents' rooms. Additionally, support plans for residents were not updated to reflect current care needs, particularly for incontinence and assistance requirements.
Complaint Details
The visit was complaint-related, triggered by concerns about sanitary conditions and resident care. The complaint was substantiated as violations were found.
Deficiencies (2)
| Description |
|---|
| Blood stains on Resident #3's pillow and a live bug crawling on the bed; strong ammonia odor and soiled bedding in Resident #1's room. |
| Resident #1 and Resident #2's support plans were not updated to reflect current medical and behavioral care needs. |
Report Facts
Residents served: 48
License capacity: 77
Total daily staff: 48
Waking staff: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to enforcement and follow-up of care and cleanliness | |
| Med Tech Supervisor | Named in relation to enforcement and follow-up of care and cleanliness |
Inspection Report
Census: 48
Capacity: 77
Deficiencies: 0
Aug 23, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 48
License Capacity: 77
Current Hospice Residents: 4
Total Daily Staff: 49
Waking Staff: 37
Residents Age 60 or Older: 48
Residents with Mobility Need: 1
Residents with Physical Disability: 2
Inspection Report
Original Licensing
Census: 40
Capacity: 40
Deficiencies: 7
Mar 1, 2022
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing inspection for the newly licensed facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the inspection was partial due to the new legal entity status. Several deficiencies were identified including hot water temperature exceeding 120°F, missing emergency telephone numbers, incomplete first aid kits, presence of a prohibited portable space heater, outdated fire safety inspection and fire drill, evacuation times exceeding standards, and unlocked medications in a resident's room.
Deficiencies (7)
| Description |
|---|
| Hot water temperature in the tub room next to Room #139 measured 130.2°F, exceeding the maximum allowed 120°F. |
| Telephone next to the variety store and in Room #138 did not have correct emergency and complaint hotline numbers posted. |
| First aid kit in nursing office missing CPR breathing shield and tweezers; kitchen first aid kit missing protective eyewear. |
| Portable space heater found in bathroom of Room #102, which is prohibited. |
| Most recent supervised fire drill and fire safety inspection was completed on 09/23/2019, not within the past year as required. |
| Fire drills conducted in December 2021, January 2022, and February 2022 exceeded 2.5 minutes for evacuation; no current fire safety expert letter designating safe evacuation time. |
| A bottle of Ocuvite medication was found unlocked in Resident #1's room without assessment allowing unlocked medications. |
Report Facts
License Capacity: 40
Residents Served: 40
Current Residents in Hospice: 2
Residents 60 Years or Older: 40
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 2
Hot Water Temperature: 130.2
Fire Drill Date: Sep 23, 2019
Evacuation Time: 2.5
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