Inspection Reports for Blue Bell Place
777 Dekalb Pike, Blue Bell, PA 19422, PA, 19422
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Inspection Report
Monitoring
Census: 66
Capacity: 99
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 66
Secured Dementia Care Unit Capacity: 30
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
Complaint Investigation
Census: 37
Capacity: 99
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 37
Secured Dementia Care Unit Capacity: 30
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
Renewal
Census: 59
Capacity: 99
Deficiencies: 13
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.
Deficiencies (13)
| Description |
|---|
| 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
License Capacity: 99
Secured Dementia Care Unit Capacity: 30
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
Complaint Investigation
Census: 55
Capacity: 99
Deficiencies: 8
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.
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.
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.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 99
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
Follow-Up
Census: 55
Capacity: 99
Deficiencies: 5
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.
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.
Complaint Details
The visit was complaint-related with substantiated findings of incidents involving resident altercations and failure to report incidents as required.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 55
Memory Care Unit Capacity: 30
Memory Care Residents Served: 26
Current Hospice Residents: 5
Total Daily Staff: 81
Waking Staff: 61
Inspection Report
Follow-Up
Census: 57
Capacity: 99
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| A resident was financially exploited by a staff member who altered a check and forged a guardian's signature. |
Report Facts
License Capacity: 99
Residents Served: 57
Secured Dementia Care Unit Capacity: 30
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
Renewal
Census: 58
Capacity: 99
Deficiencies: 14
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.
Deficiencies (14)
| Description |
|---|
| 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
License Capacity: 99
Secured Dementia Care Unit Capacity: 30
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
Follow-Up
Census: 36
Capacity: 99
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 36
Secured Dementia Care Unit Capacity: 30
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
Complaint Investigation
Census: 62
Capacity: 99
Deficiencies: 2
Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation following written complaints regarding resident room placement and related concerns.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 62
Secured Dementia Care Unit Capacity: 30
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
Complaint Investigation
Census: 60
Capacity: 99
Deficiencies: 5
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.
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.
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 60
Secured Dementia Care Unit Capacity: 30
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
Plan of Correction
Census: 61
Capacity: 99
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 61
Secured Dementia Care Unit Capacity: 30
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
Renewal
Census: 58
Capacity: 99
Deficiencies: 0
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
License Capacity: 99
Residents Served: 58
Secured Dementia Care Unit Capacity: 30
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
Follow-Up
Census: 70
Capacity: 99
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 70
Secured Dementia Care Unit Capacity: 30
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
Follow-Up
Census: 43
Capacity: 99
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 43
Residents in Secured Dementia Care Unit: 18
Capacity of Secured Dementia Care Unit: 30
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
Renewal
Census: 52
Capacity: 99
Deficiencies: 19
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.
Deficiencies (19)
| Description |
|---|
| 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
License capacity: 99
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
Renewal
Capacity: 99
Deficiencies: 0
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
Maximum capacity: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report
Follow-Up
Census: 39
Capacity: 99
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 99
Residents Served: 39
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 10
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Follow-Up
Census: 42
Capacity: 99
Deficiencies: 17
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.
Deficiencies (17)
| Description |
|---|
| 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
Licensed capacity: 99
Secured Dementia Care Unit capacity: 30
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
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