Inspection Reports for Bellingham at West Chester
1615 EAST BOOT ROAD,, PA, 19380
Back to Facility ProfileDeficiencies per Year
32
24
16
8
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Moderate
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Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 56
Capacity: 56
Deficiencies: 10
May 1, 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 including missing resident-home contract signatures, lack of signed resident rights statements, inadequate first aid/CPR trained staff coverage, improper certification of CPR training, insufficient procedures and maintenance for bedside mobility devices, water-stained ceiling tiles, lack of resident education on medication refusal rights, incomplete documentation in resident support plans, and unsigned support plans by participants.
Deficiencies (10)
| Description |
|---|
| Resident-home contract was not signed by the resident. |
| Resident record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| No staff person trained in first aid and certified in obstructed airway techniques and CPR was present during certain shifts with 56 residents. |
| Staff CPR training was completed through a non-certified organization. |
| Procedures for bedside mobility devices lacked periodic assessment for proper installation and maintenance. |
| Bedside mobility device was uncovered on both sides with openings measuring 27.5 x 4 inches and 19 x 4 inches. |
| Ceiling tiles in resident bedrooms and bathrooms were water stained. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident support plan did not document how transfer needs would be met or risks associated with bedside mobility device. |
| Resident participated in support plan development but did not sign the support plan. |
Report Facts
Residents served: 56
Capacity: 56
Staff: 80
Waking staff: 60
Mobility device opening 1: 27.5
Mobility device opening 1 height: 4
Mobility device opening 2: 19
Mobility device opening 2 height: 4
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/19/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 42
Memory Care Capacity: 24
Memory Care Residents Served: 12
Hospice Current Residents: 5
Residents Age 60 or Older: 54
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 21
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Total Daily Staff: 63
Waking Staff: 47
Resident Support Staff: 0
Inspection Report
Original Licensing
Census: 51
Capacity: 80
Deficiencies: 11
Feb 24, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and to assess compliance for the newly licensed personal care home facility.
Findings
The facility was found to be in substantial compliance with 55 Pa. Code Ch. 2600, with several deficiencies cited related to record confidentiality, poisonous materials, trash receptacles, bathroom ventilation, handrails, lighting, food protection, emergency procedures, fire department notification, and combustible storage. All deficiencies had plans of correction accepted and many were implemented by mid-April 2025.
Deficiencies (11)
| Description |
|---|
| Medication room in the memory care unit was unlocked, unattended, and accessible to all. |
| Poisonous materials (odor eliminator) were unlocked and accessible to residents not assessed as safe to handle poisons. |
| Full, uncovered, unattended trash can in the main kitchen. |
| Bathrooms in personal care and memory care units lacked operable ventilation fans or windows. |
| Ramp leading to main entrance lacked well-secured handrails; four poles missing or broken. |
| Room A114 lacked an operable lamp or source of lighting that can be turned on/off at bedside. |
| Uncovered tray of salad stored in the refrigerator of the main kitchen. |
| Unlabeled, undated bags of French fries, carrots, onion rings, and hashbrowns in the main kitchen freezer. |
| Emergency procedures were not posted in a conspicuous and public place in the home. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance needs. |
| Combustible and flammable materials (Fire Block Foam) located near boilers and hot water heaters. |
Report Facts
License Capacity: 80
Residents Served: 51
Memory Care Unit Capacity: 24
Memory Care Residents Served: 12
Current Hospice Residents: 5
Residents Age 60 or Older: 51
Residents with Mental Illness: 2
Residents with Mobility Need: 22
Total Daily Staff: 73
Waking Staff: 55
Inspection Report
Renewal
Census: 44
Capacity: 80
Deficiencies: 30
Jul 22, 2024
Visit Reason
The inspection was a renewal visit conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including issues with posting current license, access to records, compliance with laws, contract signatures, staff training, medication storage and administration, fire safety, and resident support plans. Plans of correction were proposed with various completion dates.
Deficiencies (30)
| Description |
|---|
| The home's current license, inspection summary, and 55 Pa. Code Chapter 2600 were not posted in a conspicuous and public place. |
| Administrator or designee did not provide immediate access to requested records in a timely manner. |
| Expired boiler or pressure vessel operation certificate and missing influenza awareness poster and smoke-free signage. |
| Resident-home contract not signed by resident with no notation explaining why. |
| Criminal background check not completed timely for staff person. |
| No staff trained in first aid and certified in obstructed airway techniques and CPR present on multiple shifts. |
| Administrator did not complete Department-approved competency-based training test. |
| Direct care staff did not complete initial direct care staff training. |
| Direct care staff did not complete required 12 hours of annual training. |
| Direct care staff did not receive required annual training topics including medication self-administration and care for residents with dementia. |
| Poisonous materials were not kept locked and inaccessible to residents. |
| Trash outside the home was left in uncovered receptacles. |
| Ceiling box for light fixture was unsecured and hanging. |
| Accumulation of lint in dryer lint trap. |
| Written emergency procedures not updated since 2018. |
| Unannounced fire drills not held monthly for several months. |
| Annual fire safety inspection not conducted since 2022. |
| Maximum safe evacuation time not specified in writing by fire safety expert; evacuation drills exceeded time limits. |
| Residents did not evacuate to designated meeting place during fire drill. |
| Home rules did not specify smoking policy; no smoke-free signage observed. |
| Menus not posted for current week or one week in advance. |
| Driver's license copy not provided for staff transporting residents. |
| Staff transporting residents had not completed initial new hire direct care staff training. |
| Prescription medications and OTC medications not stored properly; expired or damaged packaging observed. |
| Medications not available in home and glucometer not calibrated correctly. |
| Staff administered medications without completing Department-approved medication administration course. |
| Medication administration training records invalid or incomplete. |
| Resident assessments not updated timely when condition changed. |
| Support plans not signed by residents who participated in their development. |
| Direct care staff in secured dementia care unit did not complete required 6 hours of dementia care training. |
Report Facts
License Capacity: 80
Residents Served: 44
Residents Served in Secure Dementia Care Unit: 12
Staffing Hours: 64
Waking Staff: 48
Deficiency Counts: 33
Inspection Report
Renewal
Census: 44
Capacity: 80
Deficiencies: 32
Jul 22, 2024
Visit Reason
The inspection was a renewal licensing inspection conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including failure to post current license and inspection summary, delayed access to requested records, expired boiler certificate, missing influenza and smoke-free signage, incomplete contract signatures, incomplete criminal background checks, lack of staff CPR/first aid training, incomplete direct care staff training, unsafe storage of poisonous materials, uncovered trash receptacles, maintenance issues, medication storage and administration deficiencies, incomplete fire drills and safety inspections, and incomplete resident assessments and support plan signatures.
Deficiencies (32)
| Description |
|---|
| Current license and inspection summary not posted in a conspicuous place. |
| Delayed access to requested records by Department agents. |
| Expired boiler or pressure vessel operation certificate. |
| Influenza awareness poster not posted. |
| No smoke-free community signage observed. |
| Resident-home contract not signed by resident. |
| Criminal background checks not completed prior to hire. |
| No staff trained in first aid and certified in CPR on multiple shifts. |
| Administrator did not complete required competency-based training test. |
| Direct care staff did not complete initial direct care training. |
| Direct care staff did not complete required 12 hours of annual training. |
| Direct care staff did not receive required annual training topics. |
| Poisonous materials not locked and accessible to residents unable to safely use or avoid them. |
| Trash outside home not kept in covered receptacles. |
| Ceiling light fixture unsecured and hanging. |
| Lint accumulation in dryer lint trap. |
| Written emergency procedures not updated since 2018. |
| Unannounced fire drills not held monthly for several months. |
| Fire safety inspection not conducted annually. |
| Residents unable to evacuate entire building within specified time during fire drills. |
| Residents did not evacuate to designated meeting place during fire drill. |
| Home rules do not specify smoking policy. |
| Menus not posted one week in advance. |
| Driver's license not provided for staff transporting residents. |
| Staff transporting residents did not complete required direct care training. |
| Medications not stored properly; expired or damaged medications observed. |
| Medications not available in home when prescribed. |
| Narcotic log not signed when medication removed. |
| Staff administered medications without completing required medication administration course. |
| Resident assessment not updated timely after condition change. |
| Support plans not signed by residents who participated in development. |
| Direct care staff in secured dementia care unit did not complete required dementia care training. |
Report Facts
License Capacity: 80
Census: 44
Secure Dementia Care Unit Capacity: 24
Secure Dementia Care Unit Census: 12
Staffing Hours: 64
Waking Staff: 48
Fines Proposed: 1080
Inspection Report
Monitoring
Census: 32
Capacity: 80
Deficiencies: 3
Dec 7, 2023
Visit Reason
The inspection was a monitoring visit conducted on 12/07/2023 to review the facility's compliance and plan of correction implementation.
Findings
The facility was found to have deficiencies related to medication storage procedures, support plan documentation for medical/dental needs, and support plan signatures. The submitted plan of correction was fully implemented as of 01/26/2024.
Deficiencies (3)
| Description |
|---|
| Medication storage procedures were not properly implemented, including incorrect calibration of devices and inaccurate documentation of readings. |
| Resident support plans did not document medical, dental, vision, hearing, or behavioral care services appropriately, including failure to address vision and hearing needs. |
| Support plans were not signed by the assessor as required. |
Report Facts
License Capacity: 80
Residents Served: 32
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 8
Hospice Residents: 3
Resident Support Staff: 40
Waking Staff: 30
Inspection Report
Complaint Investigation
Census: 23
Capacity: 80
Deficiencies: 6
Nov 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection identified multiple deficiencies including staff found sleeping while on duty, sanitary issues such as a brown smear on a banister and stained/frayed rugs, missing components in medical evaluations, incomplete medication administration records, and the absence of a current weekly activity calendar.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved staff sleeping on duty and other regulatory violations. The plan of correction was accepted and fully implemented as of the follow-up date.
Deficiencies (6)
| Description |
|---|
| Staff persons were found sleeping while on duty in the memory care and personal care units. |
| A brown smear was identified on the banister located in the memory care unit. |
| Rugs in the memory care unit were spotted, stained, torn, and frayed where the carpet meets the wood flooring. |
| Medical evaluations for certain residents were missing the height component on the form. |
| Medication administration records lacked staff initials for medication administration on multiple dates and missing diagnosis or purpose for medications for some residents. |
| The home did not have a current weekly activity calendar posted in a public and conspicuous place. |
Report Facts
Residents present: 23
Licensed capacity: 80
Staff on duty sleeping duration: 15
Staffing hours: 31
Waking staff: 23
Memory care capacity: 24
Memory care residents served: 8
Hospice residents: 4
Residents aged 60 or older: 32
Residents with mobility needs: 8
Inspection Report
Monitoring
Census: 32
Capacity: 80
Deficiencies: 13
Oct 4, 2023
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted on 10/04/2023 and 10/05/2023 to review the facility's compliance and plan of correction implementation.
Findings
The facility was found to have multiple deficiencies related to safety, medication administration, record keeping, and support plan documentation. The submitted plan of correction was determined to be fully implemented as of the follow-up dates, with ongoing audits and education planned to maintain compliance.
Deficiencies (13)
| Description |
|---|
| Poisonous materials such as toothpaste and mouthwash were unlocked and accessible to residents not assessed as capable of safe use. |
| Emergency telephone numbers were not posted by the telephone in a resident room. |
| Resident bed enabler was not covered and exceeded size requirements. |
| Medication prescribed as needed was not available in the home. |
| Medication administration records (MAR) lacked diagnosis/purpose for medications and proper documentation of doses. |
| Controlled substance sign-out sheets were not properly initialed at the time of medication administration. |
| Staff administered medications without completing required Department-approved medication administration training. |
| Resident support plans did not document use of enabler or sensory needs appropriately. |
| Residents' support plans were not signed or lacked notation of refusal/inability to sign. |
| Resident medical evaluation was not completed within 60 days prior to admission to secured dementia care unit. |
| Support plans did not identify how to meet residents' 24-hour supervision needs or responsible individuals. |
| Resident record entries were not legible, including blood glucose readings and medication administration details. |
| Resident records lacked preadmission screening documentation. |
Report Facts
License Capacity: 80
Residents Served: 32
Residents in Secured Dementia Care Unit: 9
Resident Support Staff: 53
Waking Staff: 40
Residents with Mobility Need: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Program Director | Named in multiple findings related to education, audits, and plan of correction implementation. | |
| Lead Med Tech | Involved in medication administration findings and education. | |
| Administrator | Provided education and conducted audits related to medical evaluation, record keeping, and support plans. | |
| Staff person A | Mentioned in medication administration documentation deficiency. | |
| Staff persons B, C, D | Staff who administered medications without completing required training. |
Inspection Report
Annual Inspection
Census: 28
Capacity: 80
Deficiencies: 29
Jul 24, 2023
Visit Reason
The inspection was a full, unannounced annual licensing inspection conducted on 07/24/2023 and 07/25/2023, including review of renewal, complaint, and incident reasons.
Findings
The inspection identified multiple deficiencies including contract signature issues, resident funds refund delays, missing signed statements, staff qualification and training deficiencies, medication errors, unsafe storage of poisonous materials, sanitary condition issues, hot water temperature violations, missing emergency telephone numbers, inadequate lighting, food safety violations, fire drill scheduling issues, incomplete medical evaluations, medication storage and labeling problems, and incomplete resident assessments and support plans. Plans of correction were accepted with proposed completion dates mostly by late 2023.
Deficiencies (29)
| Description |
|---|
| Resident-home contract not signed by resident and administrator |
| Refund check not issued within 30 days of discharge |
| Resident record missing signed statement acknowledging receipt of rights and complaint procedures |
| Direct care staff person missing high school diploma on file |
| No director of nursing; medication errors due to staffing and transcription issues |
| Direct care staff received insufficient annual training hours |
| Direct care staff lacked training in fire safety, resident rights, and protective services act |
| Poisonous materials unlocked and accessible to residents |
| Strong urine odor and stained carpet in resident room |
| Hot water temperature exceeded 120°F in resident bathroom |
| Emergency telephone numbers missing on or by telephones in multiple resident rooms and common areas |
| Resident lacked operable lamp at bedside |
| Unlabeled and undated food items in refrigerator |
| No thermometer in ice cream freezer |
| Opened and unsealed ice cream container |
| Lint accumulation in dryer lint traps |
| Emergency procedures not submitted to local emergency management agency in 2022 |
| Fire drills for PC and MC units held on same day, not unannounced |
| Resident medical evaluation missing special health/dietary needs, self-administration ability, and body positioning |
| Resident medical evaluation not completed annually |
| Expired medications found in medication cart |
| Medications stored improperly with missing open dates and unidentified pills |
| Medication container labeling missing direction change stickers |
| Resident medication not administered due to unavailability |
| Resident not educated on right to refuse medication |
| Annual resident assessments not completed |
| Resident assessment/support plan not signed by assessor |
| Resident support plan not revised annually |
| Direct care staff in secured dementia care unit had insufficient dementia care training hours |
Report Facts
Residents Served: 28
License Capacity: 80
Medication Errors: 19
Direct Care Staff: 45
Waking Staff: 34
Residents in Secured Dementia Care Unit: 9
Capacity of Secured Dementia Care Unit: 24
Current Hospice Residents: 3
Residents Age 60 or Older: 28
Residents with Mobility Need: 17
Direct Care Staff Annual Training Hours: 4.38
Required Dementia Training Hours: 6
Actual Dementia Training Hours: 2
Fire Drill Dates: 6
Medication Cart Audits: 100
Inspection Report
Follow-Up
Census: 19
Capacity: 80
Deficiencies: 14
Mar 28, 2023
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to an incident at the facility, with a plan of correction submission and document submission reviewed subsequently.
Findings
The inspection found multiple deficiencies including failure to notify the Department about staff supervision plans, unsigned resident contracts, improper treatment of residents, missing criminal background checks, incomplete staff training, unsecured medication storage, incomplete medication records, lack of documentation for secured dementia care unit admission, missing posted instructions for key-locking devices, and unsecured resident records. All deficiencies had plans of correction accepted and were implemented or directed with completion dates.
Deficiencies (14)
| Description |
|---|
| Failure to submit supervision plan or notice of suspension for staff person A after an incident and return to duty without Department approval. |
| Resident #1's home contract for move into the secured dementia care unit was not signed by the resident or administrator. |
| Resident #1 was treated without dignity and respect; staff used inappropriate language and caused agitation resulting in a skin tear. |
| Direct Care staff B did not have a criminal background check on file. |
| Staff person C did not receive required annual training in Older Adult Protective Services, incident reporting, and resident rights during the 2022 training year. |
| Two holes in the ceiling near the nurses station were present and not sealed at the time of inspection. |
| Resident's medical evaluation did not include body positioning information. |
| Prescription medications for residents #2, 3, 4, and 5 were unlocked and accessible in the medication refrigerator. |
| Resident #1's medication administration record did not indicate administration of prescribed topical concentrate used for anxiety or agitation. |
| Use of chemical restraint (PRN gel) to control aggressive behavior was not properly authorized or documented. |
| No documentation that resident #1 and designated person did not object to admission to the secured dementia care unit. |
| Directions for operating key-locking devices at the secured dementia care unit were not conspicuously posted near the door. |
| Direct care staff person B had only 26 minutes of dementia care training during the 2022 training year, less than the required 6 hours. |
| Records for all personal care home residents were unlocked, unattended, and accessible to Department staff. |
Report Facts
Residents served: 19
License capacity: 80
Residents served in secured dementia care unit: 8
Current hospice residents: 1
Residents age 60 or older: 27
Residents with mobility need: 9
Residents with physical disability: 1
Total daily staff: 28
Waking staff: 21
Inspection Report
Complaint Investigation
Census: 36
Capacity: 80
Deficiencies: 5
Nov 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 11/14/2022 and 12/06/2022 to review compliance and follow-up on a plan of correction submission.
Findings
The facility was found to have multiple violations including failure to timely report a heating system failure incident, indoor temperatures below required minimums, use of prohibited portable space heaters, and incomplete resident medical evaluations and support plan signatures. Plans of correction were accepted and implemented with ongoing monitoring.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission and exit conference held on 12/19/2022. The plan of correction was fully implemented as of 03/22/2023.
Deficiencies (5)
| Description |
|---|
| Failure to report heating system failure incident to the Department within 24 hours. |
| Indoor temperature in resident areas was around 60°F, below the required minimum of 70°F. |
| Use of prohibited portable space heaters in resident areas and front desk. |
| Resident medical evaluation not completed annually as required. |
| Resident support plan was not signed by the resident or assessor, and refusal/inability to sign was not documented. |
Report Facts
License Capacity: 80
Residents Served: 36
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Care Unit: 8
Residents with Mobility Need: 23
Residents 60 Years or Older: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Named in relation to heating system repairs and monitoring temperature compliance. | |
| Regional Director of Plant Operations | Responsible for ensuring completion of heating system repairs. | |
| Administrator | Named in relation to education on incident reporting, portable heater removal, and review of resident support plans. | |
| Interim Resident Care Director | Involved in auditing resident records for medical evaluations and support plans. | |
| Regional Director of Health Services | Involved in auditing resident records for medical evaluations and support plans. |
Inspection Report
Renewal
Census: 36
Capacity: 80
Deficiencies: 31
Jun 30, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 06/30/2022, 07/01/2022, and 07/06/2022.
Findings
The facility was found to have multiple deficiencies including issues with carbon monoxide detectors, contract signatures, resident refunds, privacy, staff qualifications, staffing levels, fire safety, environmental hazards, medication management, and resident records. Plans of correction were submitted and accepted with completion dates mostly by late 2022.
Deficiencies (31)
| Description |
|---|
| Carbon Monoxide detector for the boiler room was not hard wired and lacked a battery. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #2 did not receive required refund within 30 days of discharge. |
| Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Bathroom window in a resident room lacked shades, blinds, or shutters. |
| Direct care staff person A lacked required high school diploma, GED, or nurse aide registry status. |
| Residents in secured dementia care unit were not receiving physical or mental stimulation due to staffing shortages. |
| Staff persons A and B did not receive required fire safety orientation on first day of work. |
| Staff persons A and B did not complete emergency medical plan training within 40 hours of work. |
| Poisonous materials were unlocked and accessible to residents in secured dementia care unit. |
| Outside deck in secured dementia care unit was in disrepair with tripping hazards. |
| Hot water temperature exceeded 120°F in kitchen sink and public bathroom sink. |
| Emergency telephone numbers were not posted on or by telephone in a resident room. |
| Ramp leading to roadway from personal care common area patio lacked a handrail. |
| Walk-in freezer door did not completely close causing temperature rise and frosting. |
| Outdoor chairs obstructed safe evacuation path at personal care common area patio door. |
| Locked exterior door marked 'NOT AN EXIT' blocked egress from secured dementia care unit emergency exit door. |
| Monthly fire drills conducted by third party did not evacuate all residents and documentation was incomplete. |
| Annual fire safety inspection and fire drill by fire safety expert was not conducted in 2021. |
| Fire drill records did not include exit route used during drill. |
| Resident #3's medical evaluation did not include medication regimen. |
| Posted menus in secured dementia care unit were outdated. |
| Resident #4's record did not include a current list of medications and some medications on MAR were not current. |
| Resident #5's glucometer was not calibrated to correct date and time. |
| Resident #3's medication administration record did not indicate diagnosis or purpose for 11 medications. |
| Staff person C administered medications without maintaining compliance with annual medication administration course requirements. |
| Resident #1 was not educated on right to refuse medication and no signed documentation was provided. |
| Resident #7's preadmission screening form did not include determination that resident's needs can be met by home services. |
| Resident #1 and #3 lacked documentation that they and their designated persons did not object to admission to secured dementia care unit. |
| Gate door leading to unlevel wooded area behind home was not locked with electronic or magnetic system and was found unlocked and unattended. |
| Records for residents of secured dementia care unit were unlocked, unattended, and accessible in nurse's office. |
Report Facts
License Capacity: 80
Residents Served: 36
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents: 5
Hospice Current Residents: 9
Residents Age 60 or Older: 35
Residents with Mobility Need: 24
Residents with Physical Disability: 1
Total Daily Staff: 60
Waking Staff: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Direct care staff lacking required qualifications and missing fire safety orientation | |
| Staff Person B | Direct care staff missing fire safety orientation and emergency medical plan training | |
| Staff Person C | Staff who administered medications without maintaining compliance with medication administration course | |
| Resident Care Director | Named in multiple findings related to staffing, education, audits, and corrective actions | |
| Administrator | Named in multiple findings related to audits, education, and corrective actions | |
| Plant Operations Director | Named in multiple findings related to maintenance, safety, and corrective actions | |
| Dining Services Director | Named in findings related to freezer door and menu postings | |
| LPN Supervisor | Named in findings related to medical record audits and education |
Inspection Report
Plan of Correction
Census: 40
Capacity: 80
Deficiencies: 5
Mar 11, 2022
Visit Reason
The inspection was conducted as a follow-up review to verify that the submitted plan of correction was fully implemented following a prior incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Multiple deficiencies related to direct care staff qualifications, orientation, resident assessments, support plans, and signatures were addressed and corrected.
Deficiencies (5)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A did not receive orientation until after the first day of work. |
| Resident #1 did not have a new additional assessment completed after a significant change. |
| The support plan for resident #1 does not address behavioral or cognitive needs and degree. |
| Resident #1's support plan was not signed by the assessor and the power of attorney. |
Report Facts
License Capacity: 80
Residents Served: 40
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 7
Residents Age 60 or Older: 39
Residents with Mobility Need: 14
Residents with Physical Disability: 3
Total Daily Staff: 54
Waking Staff: 41
Inspection Report
Complaint Investigation
Census: 32
Capacity: 80
Deficiencies: 10
Sep 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at The Watermark at Bellingham.
Findings
Multiple deficiencies were identified including failures in assistance with activities of daily living, criminal background checks, direct care staff qualifications, housekeeping and maintenance, initial direct care training, surfaces cleanliness, furniture and equipment safety, preadmission screening, support plan documentation, and medical evaluations. Some plans of correction were implemented while others were not.
Complaint Details
The inspection was conducted as a complaint investigation. Substantiation status is not explicitly stated.
Deficiencies (10)
| Description |
|---|
| Resident #1 did not receive assistance with drinking as indicated in the resident's assessment and support plan. |
| Staff members A and B did not have criminal background checks on file as required. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Residents were served lunch late due to lack of staff to complete the task. |
| Direct care staff person A began providing unsupervised ADL services without completing required direct care training and competency testing. |
| Black mold was observed on the 3rd floor ceiling near the air conditioner vent by the medication room. |
| A portable air-conditioner in resident #1's apartment was not functioning and posed a tripping hazard. |
| Resident #3's preadmission screening form did not include a determination that the resident's needs could be met by the services provided by the home. |
| Resident #1 and #3's support plans did not document how dental, vision, hearing, mental health, or other behavioral care needs would be met. |
| Resident #3's initial medical evaluation did not state the need for a secure dementia unit. |
Report Facts
License Capacity: 80
Residents Served: 32
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 8
Inspection Report
Monitoring
Census: 37
Capacity: 80
Deficiencies: 6
Feb 22, 2021
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review compliance with regulatory requirements and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including incomplete resident contracts regarding payment responsibility, overdue criminal background checks for some staff, lack of timely medical evaluations following resident condition changes, incomplete preadmission screening documentation, unsigned resident support plans, and missing dementia-specific staff training. Plans of correction were submitted and accepted for all deficiencies with ongoing audits and education planned.
Deficiencies (6)
| Description |
|---|
| Resident-home contracts for residents #2 and #3 did not specify the party responsible for payment. |
| Criminal background checks for staff members A, B, and C were completed over 180 days after hiring. |
| Resident #1 did not receive a new documented medical evaluation after health condition worsened prior to the annual evaluation. |
| Resident #3's preadmission screening form was completed after admission date. |
| Resident #1's support plan was not signed by the resident or designated person and no notation of refusal was documented. |
| Direct care staff persons A and B lacked documentation of the required 6 hours of additional annual dementia-specific training. |
Report Facts
Residents served: 37
License capacity: 80
Residents served in secured dementia care unit: 5
Capacity of secured dementia care unit: 24
Residents with mobility need: 10
Residents age 60 or older: 37
Residents with physical disability: 1
Total daily staff: 47
Waking staff: 35
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