Deficiencies per Year
24
18
12
6
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 82
Capacity: 125
Deficiencies: 16
Jul 31, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including issues with resident record confidentiality, criminal background checks, staff training, furniture and equipment maintenance, medication storage and administration, support plan documentation, and staff training in dementia care. All deficiencies had plans of correction submitted and were noted as implemented or in progress.
Deficiencies (16)
| Description |
|---|
| Signage on resident's door revealed protected health information visible to the public. |
| Staff persons did not have timely completed criminal background checks. |
| Direct care staff person received only 8 hours of annual training instead of required 12 hours. |
| Direct care staff did not receive required training on safe management techniques and other specified topics. |
| Malfunctioning keypad blocked egress in the secured dementia care unit. |
| Fire extinguisher in designated smoking area lacked inspection tag. |
| Menus for current and following week were not posted in the secured dementia care unit. |
| Medications including injection pens and eye drops were stored beyond manufacturer recommended discard dates or lacked open dates. |
| Blood sugar readings were not properly recorded on medication administration records. |
| Medications were not available in the home as prescribed, including expired insulin being used. |
| Resident's blood sugar checks were not performed at prescribed times. |
| Resident assessments lacked documentation of need for assistive devices and medical diagnoses. |
| Support plans lacked signatures from residents or assessors. |
| Direct care staff in secured dementia care unit had zero hours of required dementia care training. |
| Correction fluid was used on resident's assessment records. |
| Resident's Durable Medical Equipment (DME) form was not completed on the Department's current standardized form. |
Report Facts
Residents Served: 82
License Capacity: 125
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 9
Residents Age 60 or Older: 82
Residents with Mobility Need: 33
Total Daily Staff: 115
Waking Staff: 86
Inspection Report
Complaint Investigation
Census: 76
Capacity: 125
Deficiencies: 8
Mar 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 03/24/2025.
Findings
The facility was found to have multiple deficiencies including an administrator lacking required orientation training, unsecured poisonous materials, obstructed egress routes, incomplete resident medical evaluations, medication records missing diagnosis or purpose, untimely preadmission screening and assessments, and unsigned support plans. Plans of correction were submitted and implemented by early June 2025.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information on page 2.
Deficiencies (8)
| Description |
|---|
| Administrator has not successfully completed an orientation program approved and administered by the Department. |
| Laundry room door in the Memory Care Unit was unlocked and accessible to residents, posing a risk due to poisonous materials. |
| A wood bed frame was observed obstructing egress at the Memory Care Unit's back door exit. |
| Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of emergency and health status. |
| Resident's medication administration records and pill pack did not indicate the diagnosis or purpose for the medication. |
| Resident's preadmission screening form was not completed within the required timeframe prior to admission. |
| Resident's initial assessment was not completed within 15 days of admission. |
| Staff member did not sign the support plan despite participating in its development. |
Report Facts
Residents Served: 76
License Capacity: 125
Memory Care Unit Capacity: 20
Memory Care Unit Residents Served: 19
Hospice Current Residents: 8
Residents Age 60 or Older: 75
Residents with Mobility Need: 27
Total Daily Staff: 103
Waking Staff: 77
Inspection Report
Complaint Investigation
Census: 77
Capacity: 125
Deficiencies: 6
Jan 29, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident reported at the facility.
Findings
The inspection found multiple violations related to resident abuse reporting, supervision of staff involved in abuse allegations, timely incident reporting to the Department, unsigned resident contracts, improper treatment of residents, and incomplete preadmission cognitive screening. The facility submitted a plan of correction which was determined to be fully implemented as of the inspection date.
Complaint Details
The visit was complaint-related due to an allegation that staff person A forcibly woke a resident and forced them into a shower against their will, which was not reported timely to the Department or Older Adult Protective Services. The complaint was substantiated with multiple violations found.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to Older Adult Protective Services. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report the incident to the Department within 24 hours as required. |
| Resident home contract was not signed by the resident. |
| Resident was forced to shower against their will, causing discomfort and harm to dignity. |
| Written cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit. |
Report Facts
Residents Served: 77
License Capacity: 125
Residents in Secured Dementia Care Unit: 16
Capacity of Secured Dementia Care Unit: 21
Current Residents in Hospice: 7
Residents Age 60 or Older: 76
Residents with Mobility Need: 26
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Monitoring
Census: 69
Capacity: 125
Deficiencies: 9
Dec 30, 2024
Visit Reason
The inspection was a monitoring visit conducted on December 30, 2024, to review the facility's compliance with licensing requirements and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsecured poisonous materials accessible to residents, lack of operable ventilation in bathrooms, absence of operable bedside lighting for a resident, incomplete posting of weekly menus, presence of discontinued medications in medication carts, inaccurate medication administration documentation, missing signatures on controlled substance administration, unavailable prescribed medication, and incomplete support plans addressing resident needs.
Deficiencies (9)
| Description |
|---|
| Poisonous materials were unlocked and accessible to residents not assessed as capable of safely using or avoiding poisons. |
| Bathroom for residents #1, #2, and #3 lacked an operable window or ventilation fan. |
| Resident #4 did not have access to a source of light that can be turned on/off at bedside. |
| The home's menu for the week following 12/30/2024 was not posted in the main kitchen dining area and Lilac Terrace. |
| Discontinued medications (Nystatin for resident #1; Glucagen and Glutose gel for resident #5) were found in medication carts. |
| Glucometer readings for resident #5 were either inaccurately documented or not documented on medication administration records. |
| Resident #6’s controlled substance sheet lacked the signature of the staff person who administered Clonazepam on 12/21/2024 at 9:00 pm. |
| Prescribed medication Advair for resident #5 was not available in the home on 12/30/2024. |
| Resident #1's support plan did not address the need for a mechanical soft diet as indicated in the medical evaluation. |
Report Facts
License Capacity: 125
Residents Served: 69
Residents in Secured Dementia Care Unit: 14
Hospice Residents: 9
Residents with Mobility Need: 24
Residents 60 Years or Older: 69
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Director | Named in relation to removal of poisonous materials and staff training on poisonous material safety. | |
| Maintenance Director | Responsible for repairs of exhaust fans and conducting room audits for lighting and ventilation. | |
| Executive Director | Implemented bedside lamp for resident #4 and educated residents and families about operable lighting. | |
| Dining Director | Responsible for posting menus and training kitchen staff on menu posting. | |
| Director of Wellness | Conducted training on medication administration, documentation, narcotics sign-out, and updated support plans. |
Inspection Report
Renewal
Census: 67
Capacity: 125
Deficiencies: 17
Oct 23, 2024
Visit Reason
The inspection was a renewal visit conducted on October 23 and 24, 2024, to assess compliance with licensing requirements.
Findings
Multiple deficiencies were identified including privacy violations, lack of a staff training plan, physical accommodation issues, sanitary conditions, emergency procedure deficiencies, medication administration errors, incomplete medical evaluations, and missing policies. Many corrective actions were proposed but not fully implemented as of February 27, 2025.
Deficiencies (17)
| Description |
|---|
| Privacy violation where a resident's t-shirt was lifted in front of others and unauthorized audio recording device was found without policy. |
| No staff training plan developed for 2024. |
| Resident's bedroom door in memory care unit was difficult to open, impeding access. |
| Large stain on carpet and strong urine odor in facility. |
| Dumpster outside was uncovered, violating sanitary requirements. |
| Bathroom for a resident lacked operable window or ventilation fan. |
| Accumulation of lint in commercial dryer lint trap. |
| Emergency procedures lacked contact information for each resident’s designated person. |
| Emergency exit was blocked by residents sitting in chairs. |
| No documentation of written notification to local fire department regarding home address and evacuation assistance. |
| Emergency procedures did not indicate actions for inoperable smoke detectors or fire alarms. |
| Medical evaluations missing pertinent emergency medical information and body positioning/movement stimulation details. |
| Medication administration errors including failure to sanitize hands between medications, signing before administration, and not following prescriber's orders. |
| Expired medications found and damaged medication packaging. |
| Resident assessments not completed within required timeframes. |
| Support plans not revised timely or lacking documentation of resident needs. |
| Lack of policies and procedures for managing records. |
Report Facts
License Capacity: 125
Residents Served: 67
Memory Care Unit Capacity: 21
Memory Care Residents Served: 15
Hospice Residents: 6
Staffing: 85
Waking Staff: 64
Residents Age 60 or Older: 66
Residents with Mobility Need: 18
Expired Lorazepam Syringes: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Wagner | Med Tech | Named in medication administration and handwashing deficiencies. |
| Brian Schad | Administrator | Facility administrator during inspection. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 125
Deficiencies: 2
Jul 16, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Woodbridge Place on 07/16/2024.
Findings
The investigation found that a care staff member allegedly abused a resident by slapping their hand during care, causing the resident to yell and appear scared. The staff member was suspended and later terminated following the Department of Human Services investigation. The facility submitted a plan of correction which was accepted and fully implemented.
Complaint Details
The complaint involved alleged abuse by care staff A towards resident #1, including physical mistreatment. The complaint was substantiated, resulting in suspension and termination of the staff member.
Deficiencies (2)
| Description |
|---|
| Failure to immediately submit a plan of supervision or notice of suspension for a staff member involved in alleged abuse. |
| Resident was physically abused by a care staff member who slapped the resident's hand during care, causing distress. |
Report Facts
License Capacity: 125
Residents Served: 67
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 6
Residents with Mobility Need: 25
Residents Age 60 or Older: 67
Inspection Report
Renewal
Census: 59
Capacity: 125
Deficiencies: 8
Oct 16, 2023
Visit Reason
The inspection was conducted as a renewal, provisional inspection of the facility Woodbridge Place by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/16/2023 and 10/17/2023.
Findings
The inspection found multiple deficiencies including failure to provide timely resident refunds, unlocked poisonous materials accessible to residents, damaged door latch on memory care patio entrance, insufficient emergency food and water supply, unlocked prescription medications, mislabeled medications, incomplete medication administration documentation, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by 12/14/2023.
Deficiencies (8)
| Description |
|---|
| Resident #1 was discharged but the home did not provide the required refund within 30 days. |
| Colgate's PreviDent 5000, a poisonous material, was unlocked and accessible in resident #2's room. |
| Memory care patio entrance door latch was damaged and would not open after entering the code. |
| The home did not maintain at least a 3-day supply of nonperishable food and drinking water for residents. |
| Colgate PreviDent 5000 prescribed to resident #2 was unlocked and accessible in resident #2's bathroom. |
| Resident #7 had mislabeled medication bags with conflicting administration instructions. |
| Medication administration sign-out sheets for residents #3, #4, #5, and #6 did not indicate whether medication was administered in AM or PM at the time given. |
| Resident #3, #4, #5, and #6 had incomplete or inaccurate medication administration records and documentation. |
Report Facts
License Capacity: 125
Residents Served: 59
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 16
Emergency Drinking Water Required (gallons): 177
Emergency Drinking Water Available (gallons): 25
Total Daily Staff: 84
Waking Staff: 63
Residents with Mobility Need: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Director | Named in plan of correction related to resident funds and 30-day refund. | |
| Memory Care Director | Named in plan of correction related to locking poisonous materials and medication security. | |
| Director of Engineering | Named in plan of correction related to repair of memory care patio door latch. | |
| Dining Service Director | Named in plan of correction related to emergency food and water supply. | |
| Director of Wellness | Named in plan of correction related to medication labeling, administration documentation, and staff re-education. | |
| Clinical Specialist | Involved in re-education of Memory Care staff on medication protocols. | |
| Wellness Director | Trained nurses on new medication ordering and documentation processes. |
Inspection Report
Renewal
Census: 59
Capacity: 125
Deficiencies: 12
Oct 16, 2023
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Woodbridge Place Personal Care Home on October 16 and 17, 2023.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600, with a submitted plan of correction fully implemented. Several deficiencies were identified related to resident funds refund, locking poisonous materials, maintenance of surfaces, emergency food and water supply, medication storage and labeling, and medication administration documentation, all of which had corrective actions accepted and implemented.
Deficiencies (12)
| Description |
|---|
| Resident #1 was discharged but did not receive the required refund within 30 days. |
| Colgate's PreviDent 5000 was unlocked and accessible in resident #2's room, posing a risk as not all residents can safely use poisonous materials. |
| Memory care patio door latch was damaged and would not open after entering the code. |
| The home did not maintain a 3-day supply of nonperishable food and drinking water for residents. |
| Colgate PreviDent 5000 prescribed to resident #2 was unlocked and accessible in the bathroom. |
| Resident #7 had mislabeled medication syringes with conflicting administration instructions. |
| Narcotic administration sign-out sheets for residents #3, #4, #5, and #6 lacked indication of AM or PM administration times. |
| Resident #6's glucometer did not have a glucose reading on 10/14/23, inconsistent with the MAR. |
| Resident #3's medication administration record lacked staff initials for Clonazepam doses on 09/04/23. |
| Resident #4's medication administration record lacked staff initials for Tramadol doses on 10/04/23 and 10/10/23. |
| Resident #5's medication was marked as administered but was not given on 10/09/23. |
| Resident #6's medication administration record was inconsistent with glucometer readings. |
Report Facts
License Capacity: 125
Residents Served: 59
Secured Dementia Care Unit Capacity: 21
Residents Served in Dementia Unit: 16
Hospice Residents: 6
Staffing Hours: 84
Waking Staff: 63
Emergency Drinking Water Required: 177
Emergency Drinking Water Available: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Director of Wellness | Named in multiple medication-related findings and corrective actions. | |
| Memory Care Director | Named in findings related to locking poisonous materials and medication storage. | |
| Director of Engineering | Named in corrective action for repair of memory care patio door latch. | |
| Dining Service Director | Named in corrective action for emergency food and water supply. | |
| Business Office Director | Named in corrective action for resident funds refund process. |
Inspection Report
Follow-Up
Census: 54
Capacity: 125
Deficiencies: 4
Jul 27, 2023
Visit Reason
The visit was conducted as a follow-up to a self-reported incident by the community staff member regarding staff member A's failure to provide required care and treatment to residents, including dignity and respect violations, and other related concerns.
Findings
The inspection found multiple deficiencies including failure to assist resident #1 with toileting and bowel/bladder management, disrespectful treatment of resident #2, denial of access to bedrooms by locking doors, and improper medication storage. Staff member A was suspended and terminated following investigations. Corrective actions and staff re-education were implemented.
Complaint Details
This visit was a result of a self-reported incident by the community staff member on July 10, 2023, regarding staff member A's failure to provide care and dignity to residents.
Deficiencies (4)
| Description |
|---|
| Failure to provide total physical assistance with toileting and bowel and bladder management to resident #1, resulting in discomfort due to dried fecal matter. |
| Staff member A yelled at resident #2 during an anxiety attack, failing to treat the resident with dignity and respect. |
| Residents in the memory care unit were denied access to their bedrooms due to staff member A locking doors. |
| Medication for resident #3 was open and in the medication cart without an opened on date, contrary to manufacturer instructions. |
Report Facts
License Capacity: 125
Residents Served: 54
Secured Dementia Care Unit Capacity: 21
Residents Served in Secured Dementia Care Unit: 16
Current Hospice Residents: 4
Residents Age 60 or Older: 53
Residents with Mobility Need: 25
Total Daily Staff: 79
Waking Staff: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in multiple findings related to failure to provide care, disrespectful treatment, locking resident bedrooms, and subsequent termination | |
| Staff Member B | Intervened during disrespectful treatment of resident #2 and reported concerns about resident #1 | |
| Staff Member C | Observed resident #1's condition and witnessed staff member A locking doors | |
| Director of Wellness | Director of Wellness | Conducted investigations, re-education, and medication training; responsible for quality assurance activities |
| Executive Director | Executive Director | Investigated incidents, suspended and terminated staff member A, conducted staff training on dignity and respect |
| Memory Care Director | Memory Care Director | Conducted random ADL checks and interviews, monitored compliance with dignity and respect training |
Inspection Report
Follow-Up
Census: 53
Capacity: 125
Deficiencies: 2
Jun 13, 2023
Visit Reason
The inspection visit on 06/13/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to a prior fine.
Findings
The submitted plan of correction was determined to be fully implemented, with corrective actions taken regarding medication storage and availability, including recalibration of glucometers and ensuring medication orders are reviewed weekly.
Deficiencies (2)
| Description |
|---|
| The glucometer belonging to resident #1 was not calibrated to the correct date. |
| Resident #2's prescribed medication was not available in the home on a specified date. |
Report Facts
License Capacity: 125
Residents Served: 53
Memory Care Capacity: 21
Memory Care Residents Served: 16
Residents Age 60 or Older: 52
Residents with Mobility Need: 28
Total Daily Staff: 81
Waking Staff: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Named in corrective actions for recalibrating glucometers and re-educating staff on medication audits |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 125
Deficiencies: 3
May 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with care requirements at the facility.
Findings
The inspection identified deficiencies related to failure to provide assistance with activities of daily living (ADLs) as required by resident support plans, unattended hazardous equipment in the memory care unit, and incomplete support plan revisions. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (3)
| Description |
|---|
| Failure to provide required assistance with eating and bladder/bowel management for residents as indicated in their assessment and support plans. |
| Unattended utility cart with plates, knives, spoons, and forks found in the memory care unit, posing safety hazards. |
| Support plan for resident #1 did not address changes in dietary needs, specifically diet change from mechanical soft to pureed. |
Report Facts
License Capacity: 125
Residents Served: 57
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 10
Total Daily Staff: 89
Waking Staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Conducted training on ADLs and mealtime procedures; responsible for random visits and monitoring compliance. | |
| Executive Director | Involved in conducting random checks on ADLs and discussing findings during meetings. | |
| Dietary Services Director | Conducted additional training for dietary staff and staff in the Memory Care neighborhood on dietary carts protocol and safety. | |
| LPN | Re-educated on preparing RASP/support plans and importance of updating plans with changes in resident status. |
Inspection Report
Follow-Up
Census: 58
Capacity: 125
Deficiencies: 2
Apr 19, 2023
Visit Reason
The inspection visit on 04/19/2023 was a partial, unannounced follow-up inspection triggered by an incident at the facility.
Findings
The inspection found that the facility had delayed reporting a resident abuse incident involving an altercation between two residents. The Executive Director submitted a plan of correction and retrained staff on abuse reporting timelines and procedures, which was accepted and implemented.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local area agency on aging as required by law. |
| Failure to report the incident to the Department’s personal care home regional office or complaint hotline within 24 hours as required. |
Report Facts
License Capacity: 125
Residents Served: 58
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 10
Inspection Report
Complaint Investigation
Census: 61
Capacity: 125
Deficiencies: 4
Apr 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review related to allegations of resident abuse and mistreatment at the facility.
Findings
The investigation found that staff member C engaged in abusive behavior towards residents in the secured dementia care unit, including forcibly dragging residents to their rooms, locking a resident out of their room, and causing mental anguish. The abuse was not reported immediately as required. Staff member C was suspended and subsequently terminated. Training on abuse and resident rights was conducted for staff.
Complaint Details
The complaint investigation substantiated abuse allegations against staff member C involving physical and mental abuse of residents in the secured dementia care unit. The abuse was confirmed through face-to-face interviews and written statements from staff and residents.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected resident abuse as required by law. |
| Staff member C physically abused residents by grabbing and dragging them to their rooms and locking a resident out of their room. |
| Staff member C's actions caused mental anguish and mistreatment of residents. |
| Prohibited procedures including seclusion and manual restraint were violated by staff member C's actions. |
Report Facts
Residents Served: 61
License Capacity: 125
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 10
Residents Age 60 or Older: 60
Residents with Mobility Need: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tia Hovatter | MPH, NHA, ACC, CDP, CADDCT | Conducted training on resident abuse and resident rights |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 125
Deficiencies: 2
Mar 22, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 03/22/2023 and 03/24/2023.
Findings
The facility was found to have deficiencies including a direct care staff member providing unsupervised ADL services without completing required training and competency testing, and a resident's bed equipped with an uncovered enabler bar. The submitted plan of correction was accepted and fully implemented by 04/18/2023.
Complaint Details
The inspection was triggered by a complaint and incident as stated under Inspection Information with reason 'Complaint, Incident'.
Deficiencies (2)
| Description |
|---|
| Direct care staff person provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Resident 1's bed was equipped with an enabler bar that was not covered. |
Report Facts
License Capacity: 125
Residents Served: 61
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 12
Residents with Mobility Need: 39
Residents Age 60 or Older: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness and Business Office | Named in the plan of correction related to direct care staff training deficiency. | |
| Marketing Director | Named in the plan of correction related to bed enabler safety deficiency. | |
| Director of Wellness | Named in the plan of correction related to bed enabler safety deficiency and oversight. |
Inspection Report
Follow-Up
Census: 42
Capacity: 125
Deficiencies: 5
Feb 13, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to assistance with activities of daily living, resident privacy, staffing levels, and staff orientation and training were addressed with corrective actions and training completed by the specified dates.
Deficiencies (5)
| Description |
|---|
| Resident did not receive two-person assistance with bladder management, bowel management, and ambulating as required by the resident’s assessment and support plan. |
| Photographs were taken of residents showing bruising, violating resident privacy rights. |
| Resident did not receive two-person assist care due to lack of available direct care staffing. |
| Staff persons A and B did not receive proper orientation on fire safety and emergency preparedness topics on their first day of work. |
| Staff persons A and B did not complete training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents within their first 40 scheduled work hours. |
Report Facts
License Capacity: 125
Residents Served: 42
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 14
Residents 60 Years or Older: 60
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 35
Residents with Physical Disability: 3
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Complaint Investigation
Census: 58
Capacity: 125
Deficiencies: 12
Jan 24, 2023
Visit Reason
The inspection was conducted due to complaint, incident, and monitoring reasons as part of a licensing inspection of the Personal Care Home facility.
Findings
Multiple violations were found including abuse incidents, failure to provide fire safety orientation to new staff, sanitary condition issues, medication administration errors, improper food storage, and incomplete medication records. Plans of correction were proposed but many were not implemented as of the last follow-up.
Complaint Details
The inspection was complaint-related, involving allegations of abuse and other regulatory violations. The abuse allegations were substantiated with specific incidents described involving staff members and residents.
Deficiencies (12)
| Description |
|---|
| Resident was physically abused by staff member smacking under the chin and forcibly trying to push a mouthguard into a resident's mouth. |
| New direct care staff did not receive orientation in general fire safety and emergency preparedness on their first day. |
| Sanitary conditions not maintained: glucometer readings were misdocumented between residents. |
| Food stored on the floor of the walk-in freezer. |
| Outdated or undated food items found in dry food storage. |
| Resident medication administration records missing several self-administered medications. |
| Only current prescriptions, OTC, sample and CAM medications may be kept in the home; discontinued medications were found in medication cabinets. |
| Medication labels did not match the medication administration record for several residents. |
| Medication storage procedures not properly implemented; medication unavailable when needed. |
| Medication records incomplete for insulin administration; amount administered not recorded. |
| Failure to follow prescriber's orders for medication administration; incomplete accucheck documentation. |
| Medication errors not immediately reported to resident, designated person, and prescriber. |
Report Facts
License Capacity: 125
Residents Served: 58
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 13
Residents Age 60 or Older: 56
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 39
Inspection Report
Complaint Investigation
Census: 60
Capacity: 125
Deficiencies: 22
Nov 30, 2022
Visit Reason
The inspection was conducted as a full, unannounced complaint, provisional, and incident investigation at Woodbridge Place to assess compliance with Pennsylvania Department of Human Services regulations.
Findings
Multiple violations were found related to medication administration, resident care, staff qualifications, safety procedures, and documentation. A second provisional license was issued with a plan of correction required. Fines are pending if violations are not corrected by the mandated dates.
Complaint Details
The inspection was complaint-related, provisional, and incident investigation. Specific substantiation status is not stated.
Deficiencies (22)
| Description |
|---|
| Resident 1 had an unwitnessed fall with head injury that was not reported timely to the department. |
| Resident 2 did not receive required assistance with medication administration during October and November 2022. |
| Resident 3's contract was not signed by the resident. |
| Resident 3's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person was hired without completing required criminal background check. |
| Direct care staff person B lacked a high school diploma, GED, or active registry status. |
| Staff person B did not receive required orientation on first day of work. |
| Staff person B began providing unsupervised ADL services without completing required training and competency testing. |
| Poisonous materials were unlocked and accessible to residents. |
| Hot water temperature in resident bathrooms exceeded 120°F. |
| Food leftovers were unlabeled and undated in the refrigerator. |
| Food was stored unsealed in the dry storage area. |
| Outdated and unlabeled food items were found in storage. |
| An unannounced fire drill was not conducted during January 2022. |
| Resident 4's medical evaluation did not include immunization history. |
| Resident 2 self-administers medications but was not assessed by a qualified practitioner for ability and reminders. |
| Resident 5 was administered medications by Resident 2, who is not authorized to do so. |
| Prescription medications and syringes were unlocked and accessible in resident rooms. |
| Resident 2's prescription medication was found in the room but was discontinued. |
| Resident 3 was not educated on the right to refuse medication despite belief of medication error. |
| Resident 2's assessment lacked documentation for making and keeping appointments and social activities. |
| Resident 4's assessment did not include evaluation for engaging in social and leisure activities. |
Report Facts
Census at Inspection: 60
Total Capacity: 125
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 290
Number of Violations Listed for Fine: 6
Inspection Report
Complaint Investigation
Census: 61
Capacity: 125
Deficiencies: 0
Oct 6, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on multiple dates.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint and incident related; no deficiencies or substantiation status were reported.
Report Facts
License Capacity: 125
Residents Served: 61
Memory Care Capacity: 21
Memory Care Residents Served: 20
Hospice Residents: 14
Total Daily Staff: 104
Waking Staff: 78
Residents Age 60 or Older: 59
Residents with Mental Illness: 2
Residents with Intellectual Disability: 2
Residents with Mobility Need: 43
Inspection Report
Follow-Up
Census: 63
Capacity: 125
Deficiencies: 1
Sep 19, 2022
Visit Reason
The inspection visit on 09/19/2022 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the plan of correction regarding a violation where a staff member took and published a photograph of a resident without consent, violating resident dignity and privacy. The employee resigned and staff retraining on social media policy and resident rights was directed and completed.
Deficiencies (1)
| Description |
|---|
| Staff member took and published a photograph of a resident without consent, violating dignity and privacy. |
Report Facts
License Capacity: 125
Residents Served: 63
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 10
Residents 60 Years or Older: 60
Residents with Mental Illness: 2
Residents with Intellectual Disability: 2
Residents with Mobility Need: 41
Inspection Report
Monitoring
Census: 66
Capacity: 125
Deficiencies: 3
Jul 14, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to review the facility's compliance and implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication administration, following prescriber's orders, and preadmission screening for the secured dementia care unit. Various corrective actions were taken including removal of responsible staff from medication duties, audits, and implementation of new processes to ensure compliance.
Deficiencies (3)
| Description |
|---|
| Medication Administration Record did not include staff initials for two medication administrations for Resident #1. |
| Medication prescribed for Resident #2 was not administered and refusal was not documented in the MAR. |
| Written cognitive preadmission screening for Resident #3 was completed after admission to the secured dementia care unit, not within 72 hours prior to admission. |
Report Facts
License Capacity: 125
Residents Served: 66
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Total Daily Staff: 107
Waking Staff: 80
Residents with Mobility Need: 41
Residents 60 Years or Older: 64
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Inspection Report
Census: 67
Capacity: 125
Deficiencies: 0
May 16, 2022
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/16/2022, with the reason noted as a fine.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 125
Residents Served: 67
Memory Care Capacity: 21
Memory Care Residents Served: 20
Hospice Residents: 10
Residents Age 60 or Older: 65
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 43
Residents with Physical Disability: 2
Total Daily Staff: 110
Waking Staff: 83
Inspection Report
Complaint Investigation
Census: 71
Capacity: 125
Deficiencies: 0
May 3, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple unannounced partial inspections between 05/03/2022 and 05/16/2022.
Findings
No regulatory citations or deficiencies were identified during the inspection period.
Complaint Details
The inspection was complaint-related and incident-driven, with no deficiencies found and no follow-up required.
Report Facts
License Capacity: 125
Residents Served: 71
Memory Care Capacity: 21
Memory Care Residents Served: 19
Hospice Residents: 10
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 43
Total Daily Staff: 114
Waking Staff: 86
Inspection Report
Monitoring
Census: 66
Capacity: 125
Deficiencies: 11
Jan 13, 2022
Visit Reason
The inspection was a monitoring visit conducted on January 13, 2022, to assess compliance with regulations and follow up on previous plans of correction.
Findings
Multiple medication management deficiencies were identified, including issues with prescription currency, medication storage, labeling, refusal documentation, and medication error reporting. Additional findings included incomplete resident assessments. The facility submitted plans of correction for all deficiencies, with some plans implemented and others pending.
Deficiencies (11)
| Description |
|---|
| Prescribed medication for individual #1 was in the medication cart but not listed on the medication administration record. |
| Resident #3 had medication scheduled to be discarded but still present in the medication cart. |
| Resident #2 had an opened medication not dated according to manufacturer's instructions. |
| Pharmacy label for resident #3's medication did not match the medication administration record. |
| Resident #2 was administered medication without a prescription/order and medication was not available in the home. |
| Resident #2 and #3 refused medications without physician orders permitting refusal and without physician notification. |
| Resident #2 was administered medication not prescribed and medication administration records did not indicate correct administration. |
| Medication error for Resident #3 was not properly documented or reported. |
| Medication administration training record for staff person A lacked initial training date and annual practicum documentation. |
| Resident #4 did not have a written initial assessment completed within 15 days of admission. |
| Resident #5 did not have an annual additional assessment completed as required. |
Report Facts
Census at Inspection: 66
Total Licensed Capacity: 125
Staffing Hours: 104
Waking Staff: 78
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 11
Residents with Mobility Need: 38
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 2
Residents 60 Years or Older: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the provisional license letter |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 125
Deficiencies: 16
Nov 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on November 9, 2021, to assess compliance with regulatory requirements at Woodbridge Place.
Findings
Multiple violations were found related to abuse, medication administration, sanitary conditions, medical evaluations, medication storage, refusal of medication documentation, following prescriber's orders, training records, preadmission screening, additional assessments, and support plan signatures. The facility was issued a first provisional license due to these violations and required to submit plans of correction.
Complaint Details
The inspection was complaint-driven, triggered by allegations that led to an unannounced partial inspection on November 9, 2021. The exit conference was held the same day. Follow-up submissions and reviews occurred through January 2022.
Severity Breakdown
II: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Resident neglect and failure to complete prescribed tests leading to hospitalization. | II |
| No staff trained to administer medications during the 11-7 shift; PRN medications not administered as required. | II |
| Sanitary conditions not maintained; shared testing devices between residents. | II |
| Medical evaluation not completed within required timeframe after admission. | II |
| Annual medical evaluations missing or outdated for some residents. | II |
| Medication cart left unlocked and unattended. | II |
| Medications in cart not listed on MAR; expired or unlabeled medications present. | II |
| Medications not stored under proper conditions; open medications without open dates. | II |
| Medication container missing pharmacy label or resident name. | II |
| Prescribed medication listed on MAR but not present in the home. | II |
| Refusal of medication not documented or reported to physician. | II |
| Failure to follow prescriber's orders for medication administration and treatments. | II |
| Incomplete medication administration training records for staff. | II |
| Preadmission screening form not completed within 30 days prior to admission. | II |
| Annual additional assessments not completed timely for some residents. | II |
| Support plan developed without resident's signature. | II |
Report Facts
Census at Inspection: 74
Total Licensed Capacity: 125
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 370
Calculated Fine Per Day: 222
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the licensing letter regarding provisional license issuance |
Inspection Report
Renewal
Census: 73
Capacity: 125
Deficiencies: 23
Oct 7, 2021
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing requirements for Woodbridge Place.
Findings
The inspection identified multiple violations including failure to post required notices, staffing shortages, unsafe storage of poisonous materials, sanitary issues, missing emergency phone numbers, incomplete medical evaluations, medication management deficiencies, and lack of documentation for secured dementia care unit admissions. Plans of correction were accepted for all violations with specified completion dates.
Deficiencies (23)
| Description |
|---|
| A copy of 55 Pa Code Chapter 2600 was not posted in a conspicuous and public place in the home. |
| No influenza poster posted in a conspicuous and public place in the home. |
| Waiver related to 2620.61(13) was not posted in a prominent and public location in the home. |
| Refunds for residents who passed away were not issued timely. |
| Cameras recording video present at entrance without signage notifying of recording. |
| Direct care staffing hours were below the required minimum for residents with mobility needs. |
| Direct care staffing hours during waking hours were below the required minimum. |
| Poisonous materials (moisturizer and toothpaste) were unlocked and accessible to residents not assessed as capable of safe use. |
| Ice cream freezer sliding door had black, dark substances resembling mold. |
| Full, uncovered, unattended trash can in kitchen. |
| Emergency telephone numbers for hospital and fire department not posted on or by telephones in certain rooms. |
| First aid kit in facility van missing tweezers. |
| Resident did not have an operable lamp or source of lighting at bedside. |
| Kitchen stove hood had not been serviced since June 2019. |
| Freezer temperatures in main and small kitchen freezers were above required levels. |
| Annual medical evaluation for a resident was not found. |
| Menus for current and following weeks were not posted; outdated menus were posted. |
| Resident's record did not include a current list of medications. |
| Loose pills found on medication carts; undated medication discarded and replaced. |
| Resident's medication readings did not match MAR; devices not properly labeled or calibrated. |
| No documentation for receipt of controlled substances on medication cart for a resident. |
| Staff person administered medications without completing Department-approved medication administration course. |
| Resident record lacked documentation of no objection to admission to secured dementia care unit. |
Report Facts
Census at inspection: 73
Total licensed capacity: 125
Staffing hours required: 98
Staffing hours provided: 87.5
Staffing hours provided: 90
Freezer temperature: 12
Freezer temperature: 8
Fine per day: 370
Fine per day: 222
Inspection Report
Complaint Investigation
Census: 79
Capacity: 125
Deficiencies: 1
Jul 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Woodbridge Place on 07/29/2021.
Findings
The inspection found a deficiency related to the Resident Assessment Support Plan (RASP) for resident #1, which did not include the personal care need and degree level needed for writing correspondence. The plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related. The deficiency involved incomplete documentation in the Resident Assessment Support Plan for resident #1. The plan of correction was accepted and implemented, with resident #1 having passed away on hospice services, preventing correction of the original RASP.
Deficiencies (1)
| Description |
|---|
| The Resident Assessment Support Plan (RASP) for resident #1 did not include the personal care need and degree level needed for writing correspondence. |
Report Facts
License Capacity: 125
Residents Served: 79
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 14
Residents Age 60 or Older: 77
Residents with Intellectual Disability: 2
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Total Daily Staff: 110
Waking Staff: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed the letter confirming the plan of correction was fully implemented | |
| Resident Care Director | Resident Care Director | Responsible for completing the Resident Assessment Support Plan |
| Executive Director | Executive Director | Responsible for completing random audits to assure compliance with regulation 227b |
Inspection Report
Plan of Correction
Census: 83
Capacity: 125
Deficiencies: 1
May 4, 2021
Visit Reason
The visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a criminal background check deficiency.
Findings
The submitted plan of correction was determined to be fully implemented as of the 05/04/2021 review. The facility corrected the deficiency regarding the lack of documentation for a criminal background check for a staff member.
Deficiencies (1)
| Description |
|---|
| Failure to provide documentation that a criminal background check was processed for a staff person. |
Report Facts
Residents Served: 83
License Capacity: 125
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Inspection Report
Complaint Investigation
Census: 85
Capacity: 125
Deficiencies: 12
Mar 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident care and compliance with regulations.
Findings
The inspection identified multiple deficiencies including failure to provide prescribed wound care treatments, neglect and abuse related to resident choking and dietary needs, medication administration errors, incomplete resident records, and failure to complete required assessments and support plans. Plans of correction were accepted and implemented.
Complaint Details
The inspection was complaint-driven, triggered by allegations of neglect, abuse, medication errors, and failure to meet resident care needs. The complaint was substantiated with multiple violations found.
Deficiencies (12)
| Description |
|---|
| Failure to provide prescribed Triad Wound PST Dressing every shift as ordered, resulting in increased wound pain and hospitalization. |
| Neglect and abuse including failure to attend to a resident choking on food, failure to follow dietary needs, and inadequate supervision in the secure dementia unit. |
| Failure to meet resident special dietary needs as prescribed, including serving large pieces of meat to a resident requiring minced food. |
| Failure to document refusal of medication and failure to notify prescriber within required timeframe. |
| Failure to follow prescriber's orders for wound care treatments and medication administration. |
| Failure to immediately report medication errors to resident, designated person, and prescriber. |
| Incomplete preadmission screening forms and cognitive screening for residents admitted to the secure dementia care unit. |
| Failure to obtain documentation that resident and designated person have not objected to admission or transfer to secure dementia care unit. |
| Failure to complete admission support plans within required timeframe for residents admitted to secure dementia care unit. |
| Failure to make resident records available to designated person upon request. |
| Incomplete resident record content including missing color of hair, eyes, identifying marks, and missing assessments and support plans. |
| Failure to maintain resident records for minimum required 3 years following discharge. |
Report Facts
License Capacity: 125
Residents Served: 85
Secured Dementia Care Unit Capacity: 21
Residents Served in Secured Dementia Care Unit: 19
Residents with Wounds: 2
Residents with Wounds Before Intervention: 13
Inspection Report
Complaint Investigation
Census: 85
Capacity: 125
Deficiencies: 13
Mar 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident care, medication administration, dietary needs, and record keeping at Woodbridge Place.
Findings
The inspection found multiple deficiencies including failure to follow wound care orders, medication refusal documentation, dietary needs not met, inadequate choking response, incomplete resident records, and missing preadmission screenings and support plans. Plans of correction were accepted with retraining, audits, and implementation of new electronic health records.
Complaint Details
The inspection was triggered by complaints regarding wound care, choking incident, medication administration, dietary compliance, and record keeping deficiencies at the facility.
Deficiencies (13)
| Description |
|---|
| Failure to apply prescribed Triad Wound PST Dressing every shift as ordered, resulting in increased wound pain and hospitalization. |
| Resident #3 choked on large pieces of meat despite dietary orders for minced food, and was not immediately attended to. |
| Resident #1 refused prescribed medications on 2/20/21 and 2/21/21 without physician notification. |
| Medication error not reported when Triad wound dressing was unavailable due to backorder on 2/10/21 and 2/11/21. |
| Resident #3's preadmission screening form did not include determination that needs could be met by the home. |
| Resident #3 did not have an assessment completed for significant changes after admission to Secure Dementia Care Unit. |
| Resident #1's support plan did not include a plan for wound care of stage 2 wounds upon admission. |
| Resident #3 did not have a written cognitive preadmission screening completed within 72 hours prior to admission to Secure Dementia Care Unit. |
| Resident #2's record lacked documentation that resident and family did not object to admission to Secure Dementia Care Unit. |
| Resident #2 and #3 did not have initial support plans completed within 72 hours of admission to Secure Dementia Care Unit. |
| Resident #3's designated person was initially refused access to resident records. |
| Resident #1's record lacked color of hair, color of eyes, and identifying marks; Resident #2's record lacked assessment and support plan. |
| Resident #3's discharged records were incomplete, missing DME and preadmission screening. |
Report Facts
License Capacity: 125
Residents Served: 85
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 10
Total Daily Staff: 113
Waking Staff: 85
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Sep 29, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate the 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 is a license renewal notice confirming the issuance of a regular license based on the renewal application.
Report Facts
Maximum licensed capacity: 125
Secure Dementia Care Unit capacity: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
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