12 Reports
Inspection Report — May 14, 2026
Complaint Investigation
Date: May 14, 2026
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse and other concerns at the facility.
Complaint Details
The visit was complaint-related due to allegations of abuse involving staff. The allegations were investigated, with some found unfounded. The home failed to report abuse incidents timely and did not suspend or supervise a staff member as required. The complaint was addressed with accepted plans of correction.
Findings
The facility was found to have failed to immediately suspend or supervise a staff member involved in abuse allegations, failed to report three abuse incidents to the Department timely, and allowed a staff person to administer medication without current Department-approved competency. Plans of correction were accepted and implemented.
Citations (3)
15b Supervisor Plan: The home did not suspend or implement a supervision plan for a staff member involved in abuse allegations and allowed the staff member to continue working as scheduled.
16c Written Incident Report: The home failed to report three incidents of abuse to the Department within the required 24-hour timeframe.
190a Completion Medication Course: A staff person administered medication without having a current Department-approved medication administration course and competency.
Report Facts
Residents Served: 63
Secured Dementia Care Unit Residents Served: 23
Resident Support Staff: Staff counts are not census and thus not extracted
Total Daily Staff: 86
Waking Staff: 65
Inspection Report — Nov 24, 2025
Monitoring
Date: Nov 24, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility's compliance with licensing regulations.
Findings
Multiple deficiencies were identified related to resident personal equipment, poisonous material storage, food safety, medical evaluations, medication administration, and documentation. The facility submitted plans of correction which were accepted and later implemented.
Citations (13)
81b Resident Personal Equipment: Bedside mobility device had an opening exceeding FDA entrapment guidelines and was loosely covered.
82b Poisonous Material Storage: Poisonous cleaning materials were stored next to food items in the secured dementia care unit kitchenette.
85d Trash Receptacles: A 3/4 full, uncovered, unattended trash can was observed in the secured dementia care unit kitchenette.
103c Food Protected: Uncovered serving trays with various foods were found in the secured dementia care unit kitchenette.
103i Outdated Food: Unlabeled and undated food items were found in multiple kitchen storage areas including the secured dementia care unit kitchenette and main kitchen.
125a Combustible Storage: Combustible items including a cake box, iPad, and walkie talkie were stored on the electric stove in the secured dementia care unit kitchenette.
141a Medical Evaluation: Resident medical evaluation was not completed within required timelines prior to or shortly after admission.
181f Record of Medication: Resident record lacked a current list of medications and included discontinued medications.
182b Prescription Medication: Staff person without required qualifications administered medications to residents.
183d Prescription Current: Discontinued medication was kept in the home's medication cart.
184a Resident's Meds Labeled: Pharmacy label did not reflect changes in physician's taper order for a resident's medication.
187b Date/Time of Medication Admin.: Medication administration record lacked staff initials for administration times.
187d Follow Prescriber's Orders: Resident was administered medication contrary to prescribed taper schedule.
Report Facts
Residents Served: 52
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 1
Residents Age 60 or Older: 52
Residents with Mobility Need: 29
Inspection Report — Oct 2, 2025
Monitoring
Date: Oct 2, 2025
Visit Reason
The inspection was a monitoring visit conducted on 10/02/2025 to review compliance with licensing requirements at The Residence at Bala Cynwyd.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. Two deficiencies were identified related to incomplete resident assessments and medical evaluations, both of which were corrected with updated documentation and staff training.
Citations (2)
225c Additional Assessment: A resident's status change assessment did not include the specific need, intended use, risks, safe use ability, and device identification for a bedside mobility device as required.
231b Medical Evaluation: A resident admitted to the Secured Dementia Care Unit lacked documentation of the need for secured unit placement in the medical evaluation within 60 days prior to admission.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 27
Residents with Mobility Need: 29
Residents Age 60 or Older: 55
Inspection Report — Jul 30, 2025
Follow-Up
Date: Jul 30, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The facility was found to have left a resident unattended in a hot van for approximately three hours during an outing, violating resident supervision and safety requirements. Additional deficiencies included incomplete cognitive preadmission screenings and inaccurate support plans regarding assistive device use.
Citations (5)
21 - Offsite Services: Resident was left behind in the home's van for about three hours after an outing due to staff distraction and lack of a resident sign-out process.
23a - Activities of Daily Living Assistance: Resident requiring extensive supervision was left unaccompanied in the van for approximately three hours after an outing.
42b - Abuse: Resident was neglected when left alone in a hot van for about three hours, resulting in hospitalization with a high body temperature.
231c - Preadmission Screening: Cognitive preadmission screenings for residents admitted to the secured dementia care unit were incomplete, missing diagnoses and signatures.
234b - Support Plan Needs Elements: Resident's support plan did not reflect the use of an assistive device for ambulation despite observed use of a walker.
Report Facts
Residents served: 64
Secured Dementia Care Unit Residents Served: 24
Staff Total Daily: 97
Staff Waking: 73
Notice — May 9, 2025
Date: May 9, 2025
Visit Reason
This document serves to notify the facility that a waiver request to Pennsylvania Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows an employee educated outside the United States to serve in a direct care position under specified conditions, including documentation requirements and annual review during inspections.
Notice — Apr 29, 2025
Date: Apr 29, 2025
Visit Reason
The document serves to notify the facility that a waiver request for a direct care staff person who obtained their education outside the United States has been granted under Pennsylvania regulations.
Findings
The waiver is granted with conditions requiring documentation of education and training to be maintained and made available upon request. The Department will review the waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations at the facility.
Complaint Details
The visit was complaint-related as indicated by the inspection information section. The complaint involved issues such as unauthorized restraints and denial of access to resident records. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
Multiple deficiencies were found including denial of resident record access, use of restraints by a private duty aide, unqualified direct care staff, unlocked poisonous materials accessible to residents, prohibited procedures involving restraints, incomplete dietary assessments, and missing death certificates in resident records. Plans of correction were accepted and implemented by early June 2025.
Citations (7)
Staff person denied resident's designated person access to the resident's record.
Resident was restrained with an unauthorized waistband belt by a private duty aide.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Poisonous materials (toothpaste labeled 'contact poison control') were unlocked and accessible to residents not assessed as capable of safe use.
Prohibited procedure: private duty aide strapped resident to wheelchair with waistband belt.
Resident's assessment and support plan did not document how restricted lactose dietary need would be met.
Resident record did not include the death certificate after resident expired in the home.
Report Facts
Residents Served: 49
Memory Care Unit Residents Served: 23
Hospice Current Residents: 2
Resident with Mobility Need: 35
Resident 60 Years or Older: 49
Resident Records Deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided education on residents' rights, restraint policy, and regulations; led in-service on obtaining death certificates. | |
| Resident Care Director | Responsible for corrective actions related to restraints, dietary assessments, and audits of private duty aides. | |
| Business Office Director | Conducted audits of associate files and implemented checklists for credential verification and move-out documentation. | |
| Reflections Director/Resident Services Supervisor | Responsible for daily rounds to ensure poisonous materials are locked and inaccessible. |
Inspection Report — Aug 29, 2024
Monitoring
Date: Aug 29, 2024
Visit Reason
The inspection was a partial, announced visit conducted for new monitoring purposes at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 68
Waking Staff: 51
Residents Served: 40
Secured Dementia Care Unit Residents Served: 21
Residents Age 60 or Older: 40
Residents with Mobility Need: 28
Inspection Report — Aug 19, 2024
Renewal
Date: Aug 19, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/19/2024.
Findings
The report found multiple deficiencies including issues with resident contract signatures, ceiling water damage, incomplete first aid kits, inoperable bedside lamps, outdated food labeling, menu posting, medication availability, and record entry legibility. All deficiencies had plans of correction accepted and were implemented by 10/22/2024.
Citations (8)
Resident #1's contract contained a statement acknowledging receipt of resident rights, but the resident's signature was effaced with correction fluid.
One ceiling tile was removed due to water damage from a roof leak, with a bucket placed in the hallway to contain leaking.
The first aid kit in the kitchen and behind the front desk did not include a thermometer; a complete first aid kit was not located.
The bedside lamp for the resident in room 215 could not be turned on because it was unplugged.
Tupperware containers of corn and tuna in the kitchen refrigerator were labeled but undated.
The home's menu for the week of 8/18-8/24/2024 was posted, but the menu for the week in advance was not posted.
Medications prescribed for Resident #2 and Resident #3 were not available on the medication cart on 8/19/2024.
Correction fluid was used on Resident #1's signature on the list of resident rights in the resident's contract.
Report Facts
Residents Served: 45
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 45
Residents with Physical Disability: 32
Total Daily Staff: 45
Waking Staff: 34
Inspection Report — Jul 10, 2023
Follow-Up
Date: Jul 10, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to failure to report suspected resident abuse, failure to report a significant fall injury, and incomplete cognitive preadmission screening for a resident admitted to the secured dementia care unit. Plans of correction were accepted and implemented.
Citations (3)
Failure to immediately report suspected verbal and physical abuse of residents involving resident #1 and #2 to the Area Agency on Aging.
Failure to report an unwitnessed fall resulting in a closed fracture of multiple ribs of resident #1 to the Department within 24 hours.
Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to the secured dementia care unit for resident #2.
Report Facts
Residents Served: 24
Secured Dementia Care Unit Residents Served: 8
Total Daily Staff: 32
Waking Staff: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations | Educated Executive Director and Resident Care Director on reporting requirements and regulatory compliance | |
| Executive Director | Verbalized lack of understanding of reporting regulations related to abuse and injury reporting | |
| Resident Care Director | Educated on reporting requirements and regulatory compliance |
Inspection Report — Jun 26, 2023
Monitoring
Date: Jun 26, 2023
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes on 06/26/2023.
Findings
The inspection identified multiple deficiencies including missing emergency telephone numbers in resident bedrooms, improper freezer temperatures, outdated food items, medication administration documentation errors, failure to follow prescriber's orders, and incomplete resident record content. Plans of correction were accepted and implemented with ongoing audits and retraining.
Citations (6)
No emergency telephone numbers including nearest hospital and fire department posted on or by telephones in bedrooms 202 and 406.
Memory care freezer temperature was 6°F and walk-in freezer temperature was 10°F, exceeding required limits.
Open and undated bags of food (Porcini Mushrooms, Spaghetti, Rice) found in dry food storage.
Medication administration records lacked initials of staff administering medication and documentation inconsistencies for multiple residents.
Failure to follow prescriber's orders including missed medication administrations and double dosing documented on controlled substance log.
Resident records missing hair color, eye color, and identifying marks.
Report Facts
Residents Served: 21
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 1
Residents Age 60 or Older: 21
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Rice | Executive Director | Named as responsible party for medication administration and record content deficiencies and related corrective actions. |
| Rattana Herman | Resident Service Specialist | Named in relation to medication administration deficiency and corrective actions. |
Inspection Report — Feb 16, 2023
Date: Feb 16, 2023
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 02/16/2023 for the facility THE RESIDENCE AT BALA CYNWYD.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 0
Viewing
Loading inspection reports...
