Inspection Reports for
Blue Bell Place
777 Dekalb Pike, Blue Bell, PA 19422, PA, 19422
Back to Facility Profile36 Reports
Inspection Report — May 4, 2026
Renewal
Date: May 4, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, insufficient first aid/CPR trained staff, lack of operable bedside lamps, outdated food labeling, missing fire department notification, incomplete medical evaluations, medication storage and documentation issues, and incomplete resident records. The facility submitted plans of correction which were accepted and implemented.
Citations (15)
Criminal background checks were not completed timely for certain staff and hospice workers at the home.
At times when 77 residents were present, there was only one staff trained in first aid and certified in obstructed airway techniques, not meeting the requirement of one per 50 residents.
Resident #1 did not have access to an operable lamp or other source of lighting that can be turned on at bedside.
An unlabeled, undated bag of breaded eggplant was found in the main freezer.
The home lacked documentation of written notification to the local fire department regarding the home's address, bedroom locations, and evacuation assistance needed.
Resident #1's medical evaluation lacked documentation of body positioning and assistive device use despite using a bedside mobility device.
Resident #2 stored medications in an unlocked cabinet and bedroom door, not secured as required.
Resident #3's record did not include a current list of medications, missing Repaglinide 0.5mg tablet.
Medication containers for residents #4 and #5 had labeling discrepancies and missing change of order stickers.
Resident #6's glucometer reading did not match the medication administration record documentation.
Resident #7's controlled medication count was inaccurate; 16 pills remained though 15 were documented used.
Resident #8 and #9's medication administration records lacked initials of staff administering medications at specified times.
Resident #7 was administered Tramadol Hcl 50 mg late at 10:38 am instead of prescribed times.
Resident #1's support plan did not document the bedside mobility device or related details such as intended use and risks.
Resident records for #5, #7, and #9 lacked a photograph no more than 2 years old.
Report Facts
Residents present during inspection: 77
Hospice Current Residents: 11
Residents aged 60 or older: 76
Residents with mobility need: 50
Inspection Report — Oct 30, 2025
Follow-Up
Date: Oct 30, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the correction of previously cited deficiencies.
Findings
The facility was found to have multiple deficiencies related to resident record confidentiality, staff training, poisonous materials storage and locking, trash receptacles, surfaces maintenance, medication security, following prescriber's orders, and posting of key-locking device instructions. Immediate corrective actions were taken and plans of correction were accepted with ongoing monitoring and staff training scheduled.
Citations (10)
Resident medical information and glucose monitoring logs were unlocked, unattended, and accessible in the medication room of the secure dementia care unit.
Direct care staff persons A and B did not receive required medication self-administration training during the training year.
A small blue plastic spray bottle labeled only 'cleaning spray' was found unlabeled and contents undetermined in the memory care dining room.
Odor Ban disinfectant spray was stored on top of the juice dispenser in the secure dementia care unit kitchen, not separated from food surfaces.
Odor Ban disinfectant spray and shaving cream with hazardous labels were unlocked, unattended, and accessible to residents in the secure dementia care unit.
Trash can in the secure dementia care unit kitchen was uncovered, 3/4 full, with a broken lid and closing mechanism.
The back wall in the boiler room was saturated with water and showed signs of mold and peeling wallpaper.
Resident medications and overflow medications in the secure dementia care unit medication room were unlocked, unattended, and accessible.
A resident was not administered prescribed medication at scheduled times, violating prescriber's orders.
Directions for operating the home's locking mechanism were not conspicuously posted near the secure dementia care unit entrance door.
Report Facts
Residents Served: 68
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 9
Inspection Report — Jul 7, 2025
Monitoring
Date: Jul 7, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to review compliance and verify the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to safety, medical evaluations, medication management, and documentation. Immediate corrective actions were taken, and plans of correction were accepted with ongoing audits and staff training scheduled to maintain compliance.
Citations (9)
Two red stop signs were posted on the double doors leading to the emergency exit from the secure dementia care unit, potentially obstructing egress.
A resident's medical evaluation for 2025 was missing from the record.
A discontinued medication (Odansetron) was still present in the medication cart.
A resident's tab blister pack had a punctured blister foil exposing medication to contamination.
An expired medication bottle was found in the medication cart.
A sample prescription medication lacked written instructions from the prescriber.
Resident glucometer readings did not match medication administration record (MAR) entries and the glucometer was not calibrated to the correct time.
Medication administration records were inaccurately documented, including errors in narcotic administration and missing initials on the narcotics log.
Resident received two doses of medication at 2:31am contrary to prescriber's orders; another medication was not administered as prescribed due to scheduling errors in the electronic medication administration system.
Report Facts
Residents Served: 66
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 5
Residents Age 60 or Older: 65
Residents with Mental Illness: 3
Residents with Mobility Need: 41
Residents with Physical Disability: 1
Inspection Report — Jun 2, 2025
Complaint Investigation
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following an unwitnessed fall and related concerns at the facility.
Complaint Details
The complaint investigation was substantiated based on findings of neglect and failure to report an incident timely. Resident 1 had an unwitnessed fall on 5/18/2025 and was found with injuries. Staff failed to perform required two-hour checks overnight. The incident was not reported to the Department until 5/20/2025.
Findings
The inspection found multiple deficiencies including failure to report an incident within 24 hours, neglect related to inadequate resident checks, and employment of a direct care staff member without required qualifications. Plans of correction were accepted and fully implemented by the facility.
Citations (3)
Failure to report an incident to the Department within 24 hours as required.
Resident neglect due to inadequate two-hour checks resulting in an unwitnessed fall with injury.
Direct care staff person employed without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 26
Hospice Residents: 7
Residents 60 Years or Older: 62
Residents with Mental Illness: 2
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Inspection Report — Apr 14, 2025
Renewal
Date: Apr 14, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility Blue Bell Place to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including incomplete annual training for the administrator and staff, improper food storage practices, medication storage and administration errors, incomplete medical evaluations, missing menu postings, lack of conspicuous posting of key-locking device instructions, and failure to complete additional resident assessments after behavioral incidents. Plans of correction were accepted and implemented with ongoing audits scheduled.
Citations (13)
Administrator completed only 15 hours of required 24 hours of annual training.
Direct care staff persons did not receive required annual training in fire safety and emergency preparedness.
Nineteen 5-gallon water bottles were stored directly on the floor in the commercial laundry storage area.
No thermometer present in the ice cream freezer in the main kitchen.
Food items in the kitchen were not properly covered or sealed.
Resident medical evaluations were not completed timely.
Weekly menus for current and upcoming weeks were not posted in a conspicuous and public place.
Prescription and OTC medications were not stored properly; damaged blister pack and undated insulin pen found.
Medication directions were changed but not reflected on the blister pack.
Medication administration records contained inaccurate blood glucose readings and documentation errors.
Medication administration times were not properly recorded; missed doses and uninitialed entries noted.
Resident assessments were not updated following incidents of physical aggression.
Directions for operating key-locking devices were not conspicuously posted near the devices.
Report Facts
Staffing: 95
Waking Staff: 71
Residents Served: 59
Secured Dementia Care Unit Residents Served: 24
Hospice Residents: 8
Administrator Training Hours Completed: 15
5-gallon water bottles stored on floor: 19
Inspection Report — Feb 24, 2025
Complaint Investigation
Date: Feb 24, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial review visits on 02/24/2025, 03/05/2025, and 03/06/2025 to assess compliance and plan of correction implementation.
Complaint Details
The inspection was complaint-driven and incident-related, as indicated by the reason for inspection and the detailed abuse investigation involving Resident # with a fracture and other compliance issues.
Findings
Multiple deficiencies were found including resident abuse resulting in a fracture, inadequate staff training on required topics, failure to conduct unannounced monthly fire drills properly, inaccurate fire drill records, incomplete resident assessments, and insufficient dementia care training. Plans of correction were accepted and implemented with ongoing audits and training scheduled.
Citations (8)
Resident was physically abused during incontinence care resulting in a severely displaced distal humerus fracture.
Direct Care Staff Person A did not receive required annual training on medication self-administration, dementia care, infection control, personal care needs, safe management techniques, and care for residents with mental illness.
Direct Care Staff Person A did not receive required annual training on fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention.
Monthly fire drill was announced in advance to staff and residents, violating unannounced drill requirement.
Fire drill record inaccurately listed number of residents present and evacuation time, and incorrect evacuation routes were documented.
During fire drill, not all residents evacuated; some sheltered in place in non-fire rated areas contrary to requirements.
Resident assessment did not include need for hourly checks after condition change related to wandering.
Direct Care Staff Person A working in secured dementia care unit had no hours of dementia care training during the training year.
Report Facts
Residents Served: 59
Residents in Secured Dementia Care Unit: 25
Current Hospice Residents: 7
Residents Evacuated During Fire Drill: 35
Residents Sheltered in Place During Fire Drill: 19
Residents Present During Fire Drill: 55
Elapsed Time of Fire Drill (minutes): 8
Inspection Report — Oct 28, 2024
Follow-Up
Date: Oct 28, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by complaint and incident reports to verify the implementation of a submitted plan of correction for the facility.
Complaint Details
The visit was complaint-related with substantiated findings of incidents involving resident altercations and failure to report incidents as required.
Findings
The inspection found multiple deficiencies including failure to report incidents timely, inadequate assistance with activities of daily living, resident abuse incidents, improper medication destruction, and failure to follow prescriber's orders. The facility has implemented corrective actions and ongoing monitoring to maintain compliance.
Citations (5)
Failure to report a physical altercation incident between residents to the Department within 24 hours.
Resident did not receive required assistance with reminders for eating, behaviors, and personal hygiene as indicated in the assessment and support plan.
Resident abuse incidents including physical and verbal altercations between residents and failure to complete assurance checks as required.
Discontinued medication (earwax removal drops) was not destroyed properly according to regulations and was found in the medication cart.
Failure to administer prescribed medication due to unavailability and failure to properly document medication hold in the electronic medication administration record.
Report Facts
Residents Served: 55
Memory Care Residents Served: 26
Current Hospice Residents: 5
Total Daily Staff: 81
Waking Staff: 61
Inspection Report — Oct 7, 2024
Follow-Up
Date: Oct 7, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the submitted plan of correction was fully implemented.
Findings
The facility was found to have fully implemented the plan of correction related to a resident abuse violation involving forgery and financial exploitation by a staff member. Ongoing staff training and audits were established to maintain compliance.
Citations (1)
A resident was financially exploited by a staff member who altered a check and forged a guardian's signature.
Report Facts
Residents Served: 57
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 4
Residents Age 60 or Older: 56
Residents with Mental Illness: 2
Residents with Physical Disability: 2
Residents with Mobility Need: 37
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Total Daily Staff: 94
Waking Staff: 71
Inspection Report — Mar 18, 2024
Renewal
Date: Mar 18, 2024
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 03/18/2024 to assess compliance with licensing requirements.
Findings
Multiple deficiencies were identified related to staff qualifications and training, resident accommodations and equipment safety, emergency preparedness, medication management, resident assessments, support plans, and staff training. Immediate corrective actions were taken and plans of correction were accepted with proposed completion dates mostly by April 2024.
Citations (14)
Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person B did not receive required training in medication self-administration, resident needs, dementia care, infection control, safe management techniques, and care for residents with mental illness or intellectual disability during training year 2023.
Staff person B did not receive training in emergency preparedness and crisis response during 2023; Staff person C did not receive training in fire safety and falls prevention during 2023.
Resident 1 and Resident 2's bedside mobility devices had openings exceeding FDA guidelines and lacked secure covers.
Resident 1 and Resident 2's bedside mobility devices shifted and wobbled and were not securely attached to the bed frames.
Emergency telephone numbers were not posted on or by the telephone in room 217.
The lock on the second floor hall bathroom was broken.
The fire drill record for the drill conducted on 12/7/23 did not include the exit route used, problems encountered, or whether the fire alarm or smoke detector was operative.
A discontinued medication was found in the home's medication cart for individual resident 3.
The home's medication administration training record for staff person D did not include the date and name of the trainer for the multiple choice section.
Resident 4’s initial assessment did not include behavioral and cognitive needs and had diagnoses not supported by medical evaluation.
Resident 1 and Resident 2's support plans did not document the specific need, intended use, risks, and device identification for bedside mobility devices as required.
Resident 5's initial support plan was not completed within 72 hours of admission to the Secure Dementia Care Unit.
Direct care staff person B, working in the Secure Dementia Care Unit, had only 1 hour of dementia care training during the 2023 training year instead of the required 6 hours.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 4
Residents Age 60 or Older: 57
Residents with Mobility Need: 31
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 3
Resident Care Staff Training Hours Required: 6
Inspection Report — Sep 8, 2023
Follow-Up
Date: Sep 8, 2023
Visit Reason
The inspection was conducted as a partial, unannounced incident review to verify the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to resident treatment, facility maintenance, and medication storage and administration were addressed with corrective actions and ongoing monitoring.
Citations (4)
Resident #1 was verbally abusive to staff and staff responded in a confrontational manner, violating resident dignity and respect.
The door leading to the kitchenette in memory care was not in good repair; it did not lock and was missing a screw.
Medication prescribed to Resident #1 was not available in the home at the time it was needed.
Medication prescribed to Resident #1 was not administered because it was not available in the home.
Report Facts
Residents Served: 36
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 31
Residents Age 60 or Older: 1
Residents with Physical Disability: 2
Inspection Report — Aug 14, 2023
Complaint Investigation
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation following written complaints regarding resident room placement and related concerns.
Complaint Details
The complaint investigation was substantiated regarding delays in responding to written complaints about resident room placement and failure to provide timely status reports and written decisions as required by state regulations 2600.44e and 2600.44f.
Findings
The facility failed to provide timely status reports and written decisions regarding complaints about resident room placement and alleged abuse between residents. Coaching and corrective actions were implemented to improve complaint handling and communication.
Citations (2)
Failure to provide a status report within 2 business days after submission of a written complaint regarding Resident #1's room placement.
Failure to provide a written decision within 7 days after submission of a written complaint regarding Resident #1's and Resident #2's room placement and removal request.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 7
Residents Age 60 or Older: 61
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 27
Residents with Physical Disability: 3
Inspection Report — Aug 1, 2023
Complaint Investigation
Date: Aug 1, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial review visits on multiple dates in August 2023.
Complaint Details
The inspection was complaint-driven, investigating incidents of resident-to-resident inappropriate behavior and abuse. The complaint was substantiated with findings of resident abuse and failure to report incidents.
Findings
The facility was found to have multiple violations including failure to report an incident, resident abuse, unlocked poisonous materials accessible to residents, incomplete preadmission screening forms, and untimely medical evaluations for secured dementia care unit residents. The submitted plan of correction was fully implemented by November 2023.
Citations (5)
Failure to report an incident where resident #1 kissed resident #2 uninvited and the home did not report this incident to the department.
Resident #1 displayed inappropriate affectionate behaviors towards female residents, including kissing resident #2 uninvited and exposing resident #3 who is unable to consent, with no action taken to prevent this behavior.
Bathroom cabinets in resident apartments #119 and #121 were unlocked with poisonous materials accessible to residents not assessed as safe to use them.
Resident #3’s preadmission screening form did not include the resident's ability to safely use and avoid poisonous materials.
Resident #1’s medical evaluation for admission to the secured dementia care unit was not completed within 60 days prior to admission.
Report Facts
Residents Served: 60
Residents Served in Secured Dementia Care Unit: 23
Residents with Mental Illness: 3
Residents with Physical Disability: 3
Residents with Mobility Need: 33
Residents Age 60 or Older: 60
Inspection Report — Jul 12, 2023
Plan of Correction
Date: Jul 12, 2023
Visit Reason
The inspection was a partial, unannounced visit on 07/12/2023 due to an incident, with a follow-up to review the submitted plan of correction for violations found in the July 12, 2023 inspection.
Findings
The submitted plan of correction for the July 12, 2023 inspection was determined to be not fully implemented. A specific deficiency involved failure to report an incident to the Department within the required 24-hour timeframe.
Citations (1)
The home did not report an incident involving residents to the Department until 7/10/23, despite the incident occurring on 7/6/23 and being reported internally on 7/7/23.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 5
Residents Age 60 or Older: 60
Residents with Mental Illness: 3
Residents with Intellectual Disability: 1
Residents with Mobility Need: 33
Residents with Physical Disability: 3
Inspection Report — Mar 30, 2023
Renewal
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 3
Resident Support Staff: 0
Total Daily Staff: 88
Waking Staff: 66
Residents 60 Years or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Residents with Physical Disability: 4
Inspection Report — Jun 14, 2022
Follow-Up
Date: Jun 14, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Complaint Details
The visit was incident-related, triggered by an allegation of abuse involving a staff person (Staff Person A). The complaint was substantiated as the facility suspended the staff member and developed a plan of supervision, though the plan had deficiencies and was not initially submitted to the Department as required.
Findings
The facility was found to have implemented the plan of correction related to supervision of a staff member involved in an abuse allegation, but deficiencies were noted in the initial plan of supervision and submission process. Additional deficiencies were found in medical evaluations, including missing special health or dietary needs and failure to document the need for secured dementia care placement.
Citations (4)
The plan of supervision for a staff member involved in an abuse allegation did not include how the staff member would arrive, depart, or move around the building, and was not approved by the Department.
The home did not immediately submit a plan of supervision or notice of suspension of the affected staff person to the Department's regional office.
Resident #1's medical evaluation did not include special health or dietary needs of the resident.
Resident #1's medical evaluation did not include documentation of the need to be served in a secured dementia care unit.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 5
Residents Age 60 or Older: 69
Residents with Mobility Need: 37
Residents with Physical Disability: 2
Inspection Report — Apr 13, 2022
Follow-Up
Date: Apr 13, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility.
Findings
The facility was found to have delayed reporting an incident requiring fire department intervention beyond the required 24 hours, and failed to conduct unannounced fire drills in December 2021 and January 2022 due to COVID-19 cases. Plans of correction were accepted and implemented.
Citations (2)
The home did not report an incident requiring fire department intervention within 24 hours as required.
No unannounced fire drills were held during December 2021 and January 2022.
Report Facts
Residents Served: 43
Residents in Secured Dementia Care Unit: 18
Current Hospice Residents: 3
Residents 60 Years or Older: 60
Residents with Mobility Need: 31
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Dec 6, 2021
Renewal
Date: Dec 6, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 12/06/2021 and 12/07/2021 to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including abuse, inadequate first aid/CPR coverage, sanitary condition issues, incomplete medical evaluations, menu posting violations, medication administration errors, and issues related to secured dementia care unit admissions and safety. Plans of correction were accepted and documented for all deficiencies.
Citations (19)
Resident #1 lost a $100 bet to staff member A, who took the money, constituting abuse.
Only one staff member certified in first aid and CPR was present for 52 residents during night shifts on 11/28/21 and 12/01/21.
Discarded breakfast plates and dirty dishes were observed on a table where residents were eating.
Unlabeled and undated bag of chicken, sausage, and fish found in freezer.
Resident #2 did not have a documented medical evaluation within required timeframe.
Resident #1's medical evaluation lacked special health or dietary needs, medication regimen, contraindications, side effects, and self-administration ability.
Resident #3's most recent annual medical evaluation was outdated.
Menus for weeks of December 6 and 13, 2021 were not posted; only summer menu was posted.
Resident lunch menu for week of December 6, 2021 was not posted and no advance notice was given for meal substitutions.
Resident #4's glucometer reading was not documented on medication administration record.
Medication administration record for Resident #4 lacked staff initials for medications given on 12/01/21.
Resident #4 was administered medication incorrectly twice a day from 12/01/21 through 12/06/21, not following prescriber's orders.
Medication error involving Resident #4 was not reported to resident, designated person, and prescriber until 12/07/21.
Staff member D administered medications without successfully completing Department-approved medication administration course.
Resident #5's initial assessment lacked dental, dietary, sensory, tactile needs and how these needs will be met.
Resident #1 admitted to Secure Dementia Care Unit without documentation of non-objection from resident and designated person.
Resident #1 does not have a primary diagnosis of dementia but resides in Secure Dementia Care Unit without appropriate medical evaluation addressing this need.
Gate in fenced patio area of Secure Dementia Care Unit had an inoperable magnetic locking system, posing a hazard.
Resident #4's initial support plan was not completed within 72 hours of admission to Secure Dementia Care Unit.
Report Facts
Residents served: 52
Residents in secured dementia care unit: 14
Hospice residents: 5
Staff total daily: 75
Waking staff: 56
Residents with mobility need: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Involved in abuse violation regarding $100 bet with resident #1 | |
| Staff member B | Certified in first aid and CPR, present during night shift on 11/28/21 | |
| Staff member C | Certified in first aid and CPR, present during night shift on 12/01/21 | |
| Staff member D | Administered medications without completing required medication administration course |
Inspection Report — Sep 11, 2021
Renewal
Date: Sep 11, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate the Personal Care Home Blue Bell Place, with a reminder that an annual inspection will be conducted within the next twelve months.
Findings
A regular license is being issued based on the renewal application. The Department will conduct an onsite inspection within the next twelve months and take enforcement action if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report — Apr 30, 2021
Follow-Up
Date: Apr 30, 2021
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident, including follow-up reviews related to a submitted plan of correction.
Findings
The inspection found two deficiencies: a medication administration record book was left unlocked and accessible in a public area, violating confidentiality, and a staff member engaged in disrespectful behavior towards a resident. Both deficiencies had accepted plans of correction with re-education and training scheduled.
Citations (2)
Medication administration record book (MAR) with confidential resident information was unlocked, unattended, and accessible in a public sitting area.
Staff person engaged in a shouting match with a resident, displaying disrespectful behavior.
Report Facts
Residents Served: 39
Secured Dementia Care Unit Residents Served: 10
Total Daily Staff: 62
Waking Staff: 47
Inspection Report — Mar 2, 2021
Follow-Up
Date: Mar 2, 2021
Visit Reason
The inspection was a full, unannounced visit conducted for renewal and incident review purposes.
Findings
The inspection identified multiple deficiencies including delayed incident reporting, lack of influenza posters, unsigned resident contracts and support plans, medication storage and administration issues, inadequate emergency water supply, and safety concerns such as inoperable bedside lamps and lint accumulation in dryers. All deficiencies were accepted with plans of correction implemented.
Citations (17)
Incident involving alleged rough treatment of Resident #1 was not reported to the department within 24 hours.
Influenza information poster was missing from public areas during inspection.
Resident-home contracts for residents #2 and #3 were not signed by the residents.
Resident #2's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Staff member rushed Resident #1 in an unpleasant manner, telling the resident to hurry up.
First aid kit on the facility's bus lacked thermometer, eye covering, and breathing shield.
Residents #4 and #5 did not have operable bedside lamps.
Opened food items in storage areas were not dated or sealed properly.
Lint accumulation of approximately 4 inches found in lint trap of dryer in main laundry room.
Emergency water supply was insufficient for 42 residents, with only 85 gallons available instead of required 126 gallons.
Written emergency procedures were submitted late to local emergency management agency.
Resident #4 had several unlocked, unattended medications in an unlocked cabinet in their room.
Resident #6's medication administration record did not list prescribed Vitamin D3 supplement.
Resident #6's prescribed Tylenol 325 MG as needed was not available in the home.
Resident #2 was not educated on the right to refuse medication if a medication error is suspected.
Multiple residents (#2, #3, #7, #8) participated in support plan development but did not sign the plans.
Resident #1's record did not include incident reports from 2/18/21 and 2/24/21.
Report Facts
Residents served: 42
Residents served in dementia unit: 10
Current hospice residents: 3
Residents age 60 or older: 41
Residents with mobility need: 23
Gallons of emergency drinking water required: 126
Gallons of emergency drinking water available: 85
Staff total daily hours: 65
Waking staff hours: 49
Notice — Oct 30, 2020
Date: Oct 30, 2020
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Blue Bell Place. It informs the facility that an annual inspection will be conducted 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
Inspection Report — Apr 24, 2020
Follow-Up
Date: Apr 24, 2020
Visit Reason
The visit was conducted as a follow-up review to verify that the previously submitted plan of correction was fully implemented following an incident-related inspection.
Findings
The submitted plan of correction was determined to be fully implemented. The violation involved staff verbally abusing a resident and failure to provide breakfast options, with corrective actions including staff termination and ongoing training.
Citations (1)
Regulation 42b - Abuse: A staff member verbally abused resident #1 and did not provide breakfast options as required.
Report Facts
Residents Served: 56
Residents Served in Secured Dementia Care Unit: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named as legal entity representative and involved in plan of correction |
Inspection Report — Jun 19, 2019
Annual Inspection
Date: Jun 19, 2019
Visit Reason
The inspection was an annual licensing 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 related to sanitary conditions, incomplete medical evaluations, medication administration documentation, storage procedures, environmental awareness, and resident record content. Plans of correction were submitted and partially implemented as of the approval date.
Citations (6)
2600.85a Sanitary conditions shall be maintained. Resident #1's glucometer was broken and lacked logs; a house glucometer was used without historical recordings.
2600.141a Medical evaluations were incomplete for residents #1, #2, #3, #4, and #5, missing documentation of Section 7 or Medication Addendum.
2600.185a The home failed to develop and implement procedures for safe storage and use of medications; resident #1's glucometer was broken with no logs to confirm readings.
2600.187b Medication administration records were incomplete; resident #2 refused medication but refusal was not properly documented and staff initials were missing.
2600.232d The home did not maximize resident #6's environmental awareness and independence; bedroom was not set up properly with appropriate lighting and tactile striping.
2600.252 Resident #3's record did not include a clear photo of the resident; the record contained an unclear enlarged copy of the driver's license.
Report Facts
Residents Served: 74
Memory Care Residents Served: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator / Executive Director | Named as legal entity representative and signer of plans of correction |
| Sabrina Freeman | On-site department representative during inspection | |
| Natasha Braswell | On-site department representative during inspection |
Inspection Report — Jun 10, 2019
Renewal
Date: Jun 10, 2019
Visit Reason
The document is a renewal application and license issuance for Blue Bell Place Personal Care Home. The Department acknowledges receipt of the renewal application and states that an onsite inspection will be conducted within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and certificate issuance.
Report Facts
Inspection Report — Apr 3, 2019
Complaint Investigation
Date: Apr 3, 2019
Visit Reason
The inspection was conducted as a result of an incident complaint involving allegations of abuse and mistreatment of a resident by staff.
Complaint Details
The complaint investigation substantiated that staff person A verbally abused and threatened resident #1. The staff member was suspended pending investigation and subsequently terminated. The facility implemented staff training and ongoing education to prevent future violations.
Findings
The investigation found that staff person A made derogatory and threatening statements to resident #1 and verbally abused the resident. The facility failed to immediately develop and implement a plan of supervision or suspend the staff involved. Staff person A was suspended and later terminated following the investigation.
Citations (3)
55 Pa. Code §2600.15.b: The home failed to immediately develop and implement a plan of supervision or suspend staff person A involved in an alleged abuse incident on 3-26-19.
55 Pa. Code §2600.42.b: Staff person A verbally abused resident #1 with derogatory statements while the resident was eating in the dining room.
55 Pa. Code §2600.42.c: Staff person A lacked respect for resident #1 by making inappropriate verbal comments related to the resident's medical condition.
Report Facts
Residents Served: 76
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 5
Residents Age 60 or Older: 75
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 44
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named as Legal Entity Representative and Executive Director responsible for plan of correction |
| Natasha Braswell | Department Representative | On-site inspector for the complaint investigation |
Inspection Report — Sep 24, 2018
Complaint Investigation
Date: Sep 24, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged theft and other violations at Blue Bell Place.
Complaint Details
The investigation was triggered by reports of theft of cash and credit cards from residents by a staff member. The complaint was substantiated as the employee was terminated and police were involved.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including theft by a staff member, disrespectful treatment of residents, unsanitary conditions due to sewage smell, and inadequate documentation of resident assessments. Plans of correction were partially implemented with ongoing monitoring.
Citations (4)
55 Pa. Code §2600.42(b) - Staff person stole monetary funds and credit cards from three residents while providing care.
55 Pa. Code §2600.42(c) - Staff disrupted residents' rest by entering rooms all night and collecting trash.
55 Pa. Code §2600.85(a) - Strong sewage smell was present throughout the entire second floor of the home.
55 Pa. Code §2600.227(d) - Resident #1's fall risk assessment was not documented when checks were completed; resident #3's hearing device condition was not updated, causing communication challenges.
Report Facts
Number of Residents Served: 76
Number of Residents Age 60 or Older: 75
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda C. Durso | Personal Care Administrator | Signed multiple violation reports and plans of correction |
| Mia Johnson | Human Services Licensing Supervisor | Signed cover letter and approved plans of correction |
| Natasha Braswell | Department representative conducting the inspection |
Inspection Report — Jun 11, 2018
Renewal
Date: Jun 11, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on June 11 and June 12, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident dignity, sanitary conditions, lighting, medication administration, and safety mechanisms. Plans of correction were submitted addressing each violation with steps to prevent recurrence.
Citations (10)
2600.42(c) - A resident was threatened by staff who said, "If I had a gun, I would shoot you."
2600.85(a) - Unsanitary conditions included bags of trash with soiled linen and trash emitting a strong odor near room #219 and spilled milk and food pieces on the floor in the memory care dining room.
2600.88(a) - The memory care dining room was heavily soiled with dirt and a sticky substance.
2600.101(j)(7) - The bed in room 148 lacked an operable lamp or other source of lighting that can be turned on/off from bedside.
2600.101(j)(7) - The lamp in room 148 was unplugged and the light bulb was not working.
2600.103(f) - No thermometer was found in the freezer of the Pathways memory care unit.
2600.185(b) - The home lacked a process to ensure prescribed medications are received and available for residents, including documentation and investigation of missing medications.
2600.187(a) - The medication administration record for Resident #2 did not include the diagnosis for Alendronate tablet 70 mg.
2600.187(b) - The home did not report 9 doses of missed Mirtazapine 30 mg at bedtime for Resident #3.
2600.233(c) - Directions for operating the home's locking mechanism were not conspicuously posted near the door to the Secure Dementia Care Unit.
Report Facts
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 10
Residents 60 Years or Older: 63
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 39
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Executive Director | Named as legal entity representative and personal care administrator signing plans of correction |
| Natasha Braswell | Inspector conducting the violation report |
Inspection Report — Apr 25, 2018
Complaint Investigation
Date: Apr 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged abuse by a staff person against a resident.
Complaint Details
The complaint involved an allegation of abuse by staff person A against resident #1. The allegation was substantiated as staff person A was suspended and required to remain suspended until clearance was given by the Department.
Findings
Two violations were found: one for allowing a suspended staff person to return to work before clearance, and another for staff failing to treat a resident with dignity and respect. Plans of correction were submitted and partially implemented.
Citations (2)
55 Pa.Code §2600.15(c) - The home allowed a suspended staff person to return to work prior to Department clearance after an abuse allegation.
55 Pa.Code §2600.42(c) - Staff person A failed to treat resident #1 with dignity and respect, including making mean statements and inappropriate comments.
Report Facts
Number of Residents Served: 60
Total Daily Staff: 116
Waking Staff: 87
Number of Residents Served in Secured Dementia Care Unit: 25
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 8
Number of Residents 60 Years or Older: 59
Number of Residents with Mental Illness: 2
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 58
Number of Residents with Physical Disability: 1
Inspection Report — Feb 28, 2018
Monitoring
Date: Feb 28, 2018
Visit Reason
The inspection was a provisional monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Two violations were found related to preadmission screening requirements for residents admitted to the home and secured dementia care unit. Plans of correction were submitted addressing the timing and documentation of preadmission screenings.
Citations (2)
Regulation 55 Pa. Code §2600.224(a): A determination must be made within 30 days prior to admission and documented on the Department's preadmission screening form. Resident #1's preadmission screening form was completed before admission but the timing was not compliant.
Regulation 55 Pa. Code §2600.231(c): A written cognitive preadmission screening must be completed within 72 hours prior to admission to a secured dementia care unit. Resident #2's screening was completed 12 days prior to admission, not within 72 hours.
Report Facts
Number of Residents Served: 59
Number of Residents Served in Secured Dementia Care Unit: 24
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named as legal entity representative and signer of plans of correction. |
| Patricia Adams | Regional Licensing Director | Signed the cover letter transmitting the inspection report. |
| Shawn Parker | Department representative conducting the on-site inspection. |
Inspection Report — Feb 5, 2018
Complaint Investigation
Date: Feb 5, 2018
Visit Reason
The inspection was an unannounced partial inspection triggered by an incident.
Complaint Details
The inspection was triggered by an incident involving resident #1 who experienced a change in health status. The complaint was substantiated based on the findings of delayed assessment and support plan revision.
Findings
The facility was found to have violations related to failure to complete timely resident assessments after a significant change in health status. The resident's last assessment was not amended until nearly a month after the change occurred.
Citations (2)
Regulation 55 Pa.Code §2600.225(c): The resident did not receive a timely updated assessment after a significant change in health status. The last assessment was dated 10/31/17 but was not amended until 12/17/17.
Regulation 55 Pa.Code §2600.227(c): The support plan was not revised within 30 days after the annual assessment or significant change in resident needs.
Report Facts
Number of Residents Served: 62
Number of Residents Served in Secured Dementia Care Unit: 23
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 9
Residents Age 60 or Older: 61
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 59
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named as legal entity representative and signatory on plan of correction |
| Tahesia Thomas | Department representative on-site during inspection |
Inspection Report — Sep 13, 2017
Complaint Investigation
Date: Sep 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns at Blue Bell Place.
Complaint Details
The inspection was complaint-driven with on-site inspection on 09/13/2017 and off-site on 10/20/2017. The complaint involved concerns about wound care and service delivery at the facility.
Findings
The inspection found violations related to wound care, delivery and management of services, and support plan documentation. The facility failed to follow prescriber instructions, develop written procedures for service delivery, and update the resident support plan to reflect wound care orders.
Citations (3)
Regulation 55 Pa.Code §2600.187(d): The home failed to follow the directions of the prescriber for wound care on Resident #1, including failure to change the left boot as ordered.
Regulation 55 Pa.Code §2600.223(b): The home did not develop written procedures for delivery and management of services, specifically failing to ensure hospice services were physically present in the community.
Regulation 55 Pa.Code §2600.227(c): The resident support plan was not revised within 30 days after the annual assessment to reflect wound care orders for Resident #1.
Report Facts
Number of Residents Served: 76
Number of Residents Served in Secured Dementia Care Unit: 24
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 9
Residents Age 60 or Older: 74
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Signed plan of correction documents related to violations |
| Tahesia Thomas | Department representative conducting inspection |
Inspection Report — Apr 19, 2017
Renewal
Date: Apr 19, 2017
Visit Reason
The document is a renewal notification and license issuance for Blue Bell Place Personal Care Home, indicating the Department's receipt of the renewal application and requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Mar 9, 2017
Renewal
Date: Mar 9, 2017
Visit Reason
The inspection was a licensing inspection conducted on March 9 and 10, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations were found related to unauthorized charges by staff, failure to safeguard a resident's money, and inadequate support plans for managing finances. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
Regulation 56 Pa.Code §2600.42(b): A resident was subjected to unauthorized charges and fraudulent cashing of checks by a staff member who was arrested and charged.
Regulation 56 Pa.Code §2600.42(x): The home failed to provide a system to safeguard a resident's money, specifically Resident #1 in the secured dementia care unit.
Regulation 55 Pa.Code §2600.234(b): The support plan for Resident #1 did not address the level of care needed for managing finances.
Report Facts
Number of Residents Served: 78
Number of Residents Served in Secured Dementia Care Unit: 29
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 2
Number of Residents Age 60 or Older: 77
Number of Residents with Mobility Needs: 36
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Hamilton | Administrator | Signed plans of correction and legal entity representative |
| Patricia Adams | Human Services Licensing Supervisor | Signed cover letter for inspection report |
| Tahesia Thomas | Inspector conducting the inspection on March 9 and 10, 2017 |
Inspection Report — Jul 6, 2016
Renewal
Date: Jul 6, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Blue Bell Place personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including uncovered trash receptacles, unlabeled and undated food items, excessive fire drill evacuation time, and incomplete pre-admission screening documentation. Plans of correction were submitted with specified completion dates.
Citations (4)
55 Pa.Code §2600.85(d) requires trash in kitchens and bathrooms to be kept in covered receptacles to prevent insect and rodent penetration. Two trash cans in the kitchen did not have lids.
55 Pa.Code §2600.103(a) prohibits serving or using food again if not properly labeled and dated. The walk-in refrigerator had unlabeled and undated deli meats, and the walk-in freezer had an open bag of corn and fish sticks without labels or dates.
55 Pa.Code §2600.132(d) requires residents to be able to evacuate within the time specified by a fire safety expert. A fire drill on 6/23/16 took 14 minutes and 40 seconds, exceeding the 12-minute maximum evacuation time.
55 Pa.Code §2600.224(a) requires a pre-admission screening form within 30 days prior to admission documenting the resident's service needs. The form for resident #1 did not include a determination that the home can meet the resident's needs or ensure safe use and avoidance of poisonous materials.
Report Facts
Number of Residents Served: 73
Resident Age 50 or Older: 73
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Hamilton | ED | Named in multiple plans of correction and signature on violation reports |
Document — July 17, 2017
Date: July 17, 2017
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content are available due to lack of readable content.
Report — March 22, 2016
March 22, 2016
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