Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
219% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
76% occupied
Based on a December 2024 inspection.
Census over time
Inspection Report
Monitoring
Census: 60
Capacity: 79
Deficiencies: 12
Dec 23, 2024
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review the facility's compliance and plan of correction implementation.
Findings
The inspection found multiple deficiencies related to training records, storage of poisonous materials, food storage, menu posting, medication storage and labeling, medication administration errors, preadmission screening documentation, and record entries legibility. The facility submitted plans of correction which were accepted and implemented.
Deficiencies (12)
| Description |
|---|
| Training records did not include training dates or length of training. |
| Poisonous materials were unlocked and accessible to residents. |
| Six containers of undated and unsealed ice cream were found in the personal care unit freezer. |
| Menu for the following week was not posted as required. |
| Expired and compromised medications were found stored improperly. |
| OTC medications and CAM were not labeled with resident's name. |
| Resident glucometer was not calibrated to the correct time and medication administration record errors were observed. |
| Medication prescribed as needed was not available in the home. |
| Medication administration record indicated medication was administered but corresponding narcotic control record was not signed. |
| Prescriber's orders for blood glucose readings were not followed accurately. |
| Resident preadmission screening forms did not include determination that needs could be met by the home. |
| Narcotic log entries were scribbled over without proper notation. |
Report Facts
Residents Served: 60
License Capacity: 79
Residents Served: 17
Capacity: 20
Current Residents: 5
Residents Age 60 or Older: 60
Residents with Mobility Need: 28
Containers of undated and unsealed ice cream: 6
Incorrect pre screens noted: 11
Inspection Report
Complaint Investigation
Census: 66
Capacity: 79
Deficiencies: 6
Oct 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation at White Horse Village to review compliance following a complaint.
Findings
The inspection identified multiple deficiencies including lack of required annual training for direct care staff, unlocked poisonous materials accessible to residents, improper medication administration and storage practices, and unauthorized medication changes without written orders. Plans of correction were submitted and fully implemented by March 28, 2025.
Complaint Details
The inspection was triggered by a complaint. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Direct care staff persons A and B did not receive training in medication self-administration and instructions on meeting the needs of the residents as described in the pre-screening, DME, and RASP for the annual training. |
| Colgate with a manufacturer's label indicating 'Keep out of reach of children; please contact poison control center' was unlocked, unattended, and accessible to the resident in bedroom. |
| Several small cups with medications for various residents inside of the med cart to be administered at the noon med pass were not properly managed. |
| Medications were not stored in an organized manner under proper conditions of sanitation, temperature, moisture and light as required. |
| A blister pack for a resident had an opening on the back and was taped, indicating improper medication storage. |
| Staff person A discontinued a resident's medication without a written order from an authorized prescriber and the home does not have registered nurses authorized to receive verbal orders. |
Report Facts
License Capacity: 79
Residents Served: 66
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Total Daily Staff: 92
Waking Staff: 69
Residents 60 Years or Older: 66
Residents with Mobility Need: 26
Inspection Report
Follow-Up
Census: 54
Capacity: 79
Deficiencies: 5
Dec 21, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 12/21/2023 to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including resident abuse reporting, supervision plans, staffing during activities, and resident assessments. Continued compliance must be maintained.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Failure to immediately develop and implement a plan of supervision or suspend staff person involved in alleged abuse incident. |
| Resident was physically abused by staff who forcefully pushed resident's feet into wheelchair pedals multiple times. |
| Inadequate staffing during a concert outside the secured dementia care unit, with only one direct care staff supervising residents. |
| Resident assessment did not include assessments for Behavioral/Cognitive Needs and lacked reassessment of ambulation needs. |
Report Facts
License Capacity: 79
Residents Served: 54
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 1
Resident Support Staff: 71
Waking Staff: 53
Number of Residents 60 Years or Older: 54
Number of Residents with Mobility Need: 17
Inspection Report
Renewal
Census: 20
Capacity: 79
Deficiencies: 0
Jun 14, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted on 06/14/2023 and 06/16/2023.
Report Facts
Residents Served: 20
License Capacity: 79
Secured Dementia Care Unit Capacity: 16
Current Hospice Residents: 3
Residents Age 60 or Older: 60
Residents with Mobility Need: 16
Inspection Report
Follow-Up
Census: 37
Capacity: 79
Deficiencies: 7
Aug 24, 2022
Visit Reason
The inspection was an unannounced partial inspection conducted due to an incident involving resident behavior and abuse allegations.
Findings
The facility was found to have multiple incidents of resident abuse and failure to report these incidents properly to the Department. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The visit was complaint-related due to allegations of physical and emotional abuse by resident #1 towards other residents. The allegations were substantiated by observations and reports, but the facility failed to report these incidents to the Department as required.
Deficiencies (7)
| Description |
|---|
| Resident #1 punched another resident in the face and grabbed their wrist; this physical abuse was not reported to the Department. |
| Staff person witnessed resident #1 grabbing the walker of another resident and yelling; this emotional abuse was not reported to the Department. |
| Failure to properly document incidents involving residents. |
| Failure to implement positive interventions to modify or eliminate behaviors of resident #1 that endangered others. |
| Administrator failed to report numerous incidents of resident #1's behavior towards others to the Department and failed to direct staff in utilizing positive interventions. |
| Resident #1 became verbally and physically aggressive, requiring assistance and intervention; failure to report and manage behavior properly. |
| Resident #1's most recent assessment was not completed timely; multiple incidents of abuse occurred since last assessment and resident was not re-assessed as required. |
Report Facts
License Capacity: 79
Residents Served: 37
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Residents Age 60 or Older: 57
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sr. Director of Healthcare | Sr. Director of Healthcare | Re-educated Administrator on ensuring reports are sent to required agencies |
| Administrator | Administrator | Failed to report incidents and re-educated on reporting requirements; failed to direct staff in positive interventions |
| Clinical Manager / Designee | Clinical Manager / Designee | Will conduct weekly audits of progress notes and random reviews of 24-hour reports to ensure compliance with positive interventions |
Inspection Report
Renewal
Census: 54
Capacity: 79
Deficiencies: 9
Apr 28, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for White Horse Village.
Findings
The inspection identified multiple deficiencies related to resident privacy, bathroom ventilation and lighting, medication administration documentation, medical evaluations, record storage, medication availability, and key-locking device instructions. All deficiencies had plans of correction accepted and were verified as implemented by follow-up visits.
Deficiencies (9)
| Description |
|---|
| Resident #4’s medication information was open, unattended, and accessible on the medication cart laptop. |
| Resident #5 was administered medication in a common area without proper privacy. |
| Bathroom in room 217 did not have an operable window or ventilation fan. |
| Bathroom light in room 217 did not work and was flickering. |
| Resident #3’s controlled substance log did not include initials of staff who administered medication on 5/1/22 at 6am. |
| Resident #1’s medical evaluation was not completed within 60 days prior to admission to the Secure Dementia Care Unit. |
| Resident records were stored in the nurse's office which was open and unattended with resident records accessible. |
| Resident #2’s prescribed medication was not available in the home on 5/2/22. |
| Incorrect posted directions for operating the home's locking mechanism at the exit from memory care to the courtyard. |
Report Facts
License Capacity: 79
Residents Served: 54
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 2
Total Daily Staff: 71
Waking Staff: 53
Residents 60 Years or Older: 54
Residents with Mobility Need: 17
Inspection Report
Complaint Investigation
Census: 55
Capacity: 79
Deficiencies: 0
Feb 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site inspection dates between 02/01/2022 and 02/18/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the exit conference was held on 02/18/2022. No deficiencies were found, indicating the complaint was not substantiated.
Report Facts
License Capacity: 79
Residents Served: 55
Memory Care Unit Capacity: 20
Memory Care Unit Residents Served: 15
Total Daily Staff: 55
Waking Staff: 41
Notice
Capacity: 79
Deficiencies: 0
Jun 11, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for White Horse Village Personal Care Home pursuant to Title 55, PA Code, Chapter 2600. It advises that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and outlines the requirement for an annual inspection.
Report Facts
Maximum capacity: 79
Secure Dementia Care Unit capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 44
Capacity: 79
Deficiencies: 8
Jun 2, 2021
Visit Reason
The inspection was a renewal visit conducted on 06/02/2021 and 06/03/2021 to review compliance with licensing requirements for White Horse Village.
Findings
The inspection found multiple deficiencies including failure to post the current license, expired boiler certificates, outdated food storage, unclear pet policies, limited alternate exit routes during fire drills, medication storage and availability issues, incomplete medication training records, and missing directions for key-locking devices. Plans of correction were accepted and implemented or scheduled.
Deficiencies (8)
| Description |
|---|
| The home's copy of 55 Pa. Code Chapter 2600 was not posted in a conspicuous and public place in the home. |
| Three of the home's boiler certificates expired on 5/21/21. |
| There were 12 trays of unlabeled, undated pork meat inside the freezer. |
| The home rules do not specify what kind of animals are permitted in the home. |
| The North Hall Refuge Area for Personal Care (Bridlewood) and East Exit for Dementia Unit (Four Seasons) were the only exit routes used during fire drills. |
| Resident 1's prescribed medication was not available in the home. |
| The home's medication administration training record for staff person A does not include the signature and date from the trainer. |
| Directions for operating the home's locking mechanism are not conspicuously posted on the outer door to the Secure Dementia Care Unit (SDCU). |
Report Facts
License Capacity: 79
Residents Served: 44
Residents Served in Secured Dementia Care Unit: 15
Capacity of Secured Dementia Care Unit: 20
Current Hospice Residents: 3
Number of trays of unlabeled, undated pork meat: 12
Expired Boiler Certificates: 3
Total Daily Staff: 44
Waking Staff: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Kehough | Property and Facility Manager | Responsible for audits to ensure valid boiler certificates |
Inspection Report
Follow-Up
Census: 47
Capacity: 79
Deficiencies: 13
May 19, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident (reason: Incident) to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including improper submission of final incident reports, failure to notify residents and their designated persons of validated abuse incidents, treatment of residents lacking dignity and respect, missing criminal background checks for staff, unqualified direct care staff, use of non-approved forms for medical evaluations and preadmission screenings, medication administration errors, and incomplete medication records. The submitted plan of correction was determined to be fully implemented.
Deficiencies (13)
| Description |
|---|
| Final incident reports were not submitted on Department-approved forms. |
| Lack of documentation that residents and their designated persons were notified of validated abuse incidents. |
| Residents were treated without dignity and respect; staff were reported as 'bossy' and physically squeezing a resident's nose to ensure medication ingestion. |
| No record of e-patch criminal background checks for two staff members. |
| Direct care staff persons lacked required qualifications such as high school diploma, GED, or active registry status. |
| Medical evaluations for residents were not completed on Department-approved forms. |
| Resident with difficulty swallowing was not confirmed to have ingested medication doses. |
| Medication prescribed as needed was not available in the home. |
| Medication administration record did not list a prescribed medication for a resident. |
| Medication administration times and confirmation of ingestion were not properly documented. |
| Medication refusal documentation was incomplete for a resident. |
| Preadmission screening forms were either not completed or not on Department-approved forms. |
| Written cognitive preadmission screening was not completed for a resident admitted to the secured dementia care unit. |
Report Facts
Residents Served: 47
License Capacity: 79
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 3
Residents Diagnosed with Mental Illness: 15
Residents Aged 60 or Older: 47
Residents with Mobility Need: 15
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