Inspection Reports for
White Horse Village
535 GRADYVILLE ROAD,, NEWTOWN SQUARE, PA, 19073
Back to Facility Profile23 Reports
Inspection Report — Apr 7, 2026
Follow-Up
Date: Apr 7, 2026
Visit Reason
The inspection was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to verify that the submitted plan of correction was fully implemented following a complaint and incident investigation.
Complaint Details
The inspection was complaint-related and incident-driven, involving a failure to report an incident and concerns about resident treatment and medical evaluations. The plan of correction was accepted and implemented.
Findings
The facility was found to have implemented the required corrections related to incident reporting, treatment of residents with dignity and respect, and medical evaluation documentation. Continued compliance must be maintained.
Citations (4)
16c - Written Incident Report: The home failed to report an incident involving staff and residents to the department within 24 hours as required by regulation.
42c - Treatment of Residents: A resident was embarrassed and involved in a verbal altercation with staff during a group activity, causing several residents to leave the activity.
141a - Medical Evaluation Information: A resident's medical evaluation did not indicate that the resident's needs could be met safely at the personal care home.
141b1 - Annual Medical Evaluation: A resident's most recent medical evaluation was not completed within the required annual timeframe.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 3
Residents Age 60 or Older: 55
Residents with Mobility Need: 21
Inspection Report — Dec 23, 2024
Monitoring
Date: 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.
Citations (12)
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
Residents Served: 17
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 — Oct 21, 2024
Complaint Investigation
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation at White Horse Village to review compliance following a complaint.
Complaint Details
The inspection was triggered by a complaint. The submitted plan of correction was reviewed and determined to be fully implemented.
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.
Citations (6)
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
Residents Served: 66
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 — Dec 21, 2023
Follow-Up
Date: 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.
Citations (5)
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
Residents Served: 54
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 — Jun 14, 2023
Renewal
Date: 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
Current Hospice Residents: 3
Residents Age 60 or Older: 60
Residents with Mobility Need: 16
Inspection Report — Aug 24, 2022
Follow-Up
Date: Aug 24, 2022
Visit Reason
The inspection was an unannounced partial inspection conducted due to an incident involving resident behavior and abuse allegations.
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.
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.
Citations (7)
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
Residents Served: 37
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 — Apr 28, 2022
Renewal
Date: 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.
Citations (9)
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
Residents Served: 54
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 — Feb 1, 2022
Complaint Investigation
Date: 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.
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 55
Memory Care Unit Residents Served: 15
Total Daily Staff: 55
Waking Staff: 41
Notice — Jun 11, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Jun 2, 2021
Renewal
Date: 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.
Citations (8)
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
Residents Served: 44
Residents Served in Secured Dementia Care Unit: 15
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 — May 19, 2021
Follow-Up
Date: 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.
Citations (13)
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
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
Inspection Report — Dec 11, 2020
Date: Dec 11, 2020
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 27
Secured Dementia Care Unit Residents Served: 19
Resident Support Staff: 46
Waking Staff: 35
Notice — Mar 3, 2020
Date: Mar 3, 2020
Visit Reason
This document serves as a renewal notification and license issuance for White Horse Village to operate as a Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
No inspection findings are reported in this document. It confirms the renewal application has been received and a license issued.
Report Facts
Inspection Report — Nov 18, 2019
Routine
Date: Nov 18, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the facility on November 18, 2019.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Sep 10, 2019
Renewal
Date: Sep 10, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to follow HIPAA medication labeling requirements, missing resident rights poster, privacy violations during medication administration, incomplete criminal background checks, lack of soap in memory care bathrooms, and improper food storage. Plans of correction were partially implemented with adequate progress noted.
Citations (6)
2600.18: The home failed to follow HIPAA by leaving medication labels for reorder on top of the medication cart for resident #1.
2600.41c: The Department's resident rights poster was not posted in a conspicuous and public place in the home's memory care unit.
2600.42s: A staff person provided medication in the common area to resident #2, violating privacy rights.
2600.51: The home failed to complete a federal criminal background check for staff person B as required by the Older Adult Protective Services Act.
2600.102i: There was no soap in the bathrooms of rooms 4S102 and 4S119 in memory care.
2600.103g: The home had two containers of sauce and pan of meat uncovered and unsealed in the refrigerator.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 2
Inspection Report — Feb 25, 2019
Renewal
Date: Feb 25, 2019
Visit Reason
The document is a renewal application and license issuance for White Horse Village Personal Care Home. 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.
Report Facts
Notice — Mar 6, 2018
Date: Mar 6, 2018
Visit Reason
The document serves as a renewal notification and license issuance for White Horse Village Personal Care Home following receipt of a renewal application dated February 27, 2018.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Oct 16, 2017
Annual Inspection
Date: Oct 16, 2017
Visit Reason
The inspection was conducted as the Department's Bureau of Human Services Licensing annual inspection of White Horse Village on October 16 and 17, 2017.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Notice — Feb 27, 2017
Date: Feb 27, 2017
Visit Reason
This document serves as a renewal notification for the operation of White Horse Village Personal Care Home and informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document as it is a license renewal notification letter.
Report Facts
Inspection Report — Feb 15, 2017
Annual Inspection
Date: Feb 15, 2017
Visit Reason
The inspection was an annual licensing inspection conducted by the Department of Human Services on February 15, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations related to sanitary conditions were found, including blood running down the base of a toilet in a resident's bedroom and uncovered overflowing trash in the main kitchen. Plans of correction were submitted to address these issues with daily bathroom checks and proper trash receptacle coverage and emptying.
Citations (2)
Regulation 55 Pa.Code §2600 requires sanitary conditions to be maintained. Blood was noticed running down the base of the toilet in the bedroom of resident #1 on 02-15-17.
Regulation 55 Pa.Code §2600 requires trash in kitchens and bathrooms to be kept in covered trash receptacles. On 02-16-17, a trash can in the main kitchen did not have a lid and was overflowing with trash.
Report Facts
Number of Residents Served: 61
Number of Current Hospice Residents: 2
Number of Residents 60 Years or Older: 61
Number of Residents with Mobility Need: 17
Number of Residents with Physical Disability: 1
Notice — Apr 4, 2016
Date: Apr 4, 2016
Visit Reason
The document serves as a license renewal notification and certificate for White Horse Village, confirming the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the issuance of a regular license and outlines the Department's inspection requirements.
Report Facts
Inspection Report — Feb 17, 2016
Renewal
Date: Feb 17, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspection for White Horse Village.
Findings
The inspection found violations related to 55 Pa.Code Chapter 2600, specifically the absence of emergency service telephone numbers posted near the telephone in room 231. A plan of correction was submitted to address this issue.
Citations (1)
55 Pa.Code §2600.91 requires telephone numbers for emergency services to be posted by each telephone. The telephone in room 231 did not have emergency service numbers posted nearby.
Report Facts
Number of Residents Served: 55
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 8
Number of Residents 60 Years or Older: 55
Number of Residents with Mobility Needs: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Boukalis | Senior Director | Administrator named in the report and signed plan of correction |
Document — January 6, 2017
Date: January 6, 2017
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content are present in the document.
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