Inspection Report
Complaint Investigation
Census: 70
Capacity: 95
Deficiencies: 3
Apr 18, 2025
Visit Reason
The inspection visit occurred as a complaint investigation, triggered by a complaint regarding facility operations.
Findings
The inspection identified deficiencies including the absence of a fee schedule in resident contracts, unsanitary conditions in a resident's room, and incomplete resident records lacking identifying marks and personal property inventories. Plans of correction were accepted and implemented to address these issues.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint'.
Deficiencies (3)
| Description |
|---|
| The resident-home contract does not include a fee schedule of actual amounts charged for available services. |
| Resident room had a very strong pungent odor indicating unsanitary conditions. |
| Resident records do not include identifying marks and an inventory of the resident's personal property as voluntarily declared upon admission or updated. |
Report Facts
License Capacity: 95
Residents Served: 70
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 11
Resident Diagnosed with Mental Illness: 3
Residents Age 60 or Older: 70
Residents with Mobility Need: 32
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Director | Named in relation to the plan of correction for adding a fee schedule to resident contracts. | |
| Maintenance Director | Named in relation to the plan of correction for cleaning the apartment with unsanitary conditions. | |
| Personal Care Director | Named in relation to maintaining sanitary conditions and performing weekly inspections. | |
| Health Service Director | Named in relation to updating resident records to include identifying marks and personal property inventories. |
Inspection Report
Follow-Up
Census: 70
Capacity: 95
Deficiencies: 2
Jan 16, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify the submitted plan of correction related to a complaint and incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were noted: failure to submit a final incident report immediately after investigation conclusion, and improper treatment of a resident by staff, which resulted in a minor injury without pain or bruising.
Complaint Details
The visit was complaint-related and incident-related. The complaint involved an alleged abuse incident where a staff member was terminated following an internal investigation. The complaint was substantiated as corrective actions were implemented.
Deficiencies (2)
| Description |
|---|
| Failure to submit a final incident report to the Department regional office immediately following the conclusion of the investigation. |
| A resident was treated without dignity and respect when a staff member yanked bed linens forcefully causing the resident to hit their head on a dresser. |
Report Facts
License Capacity: 95
Residents Served: 70
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 11
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 3
Residents with Mobility Need: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Directed submission of final incident report and conducted training on timely submission of incident reports. | |
| Health Service Director | Assessed resident for injury, reported incident to doctor, family, and state agencies, and managed internal investigation leading to staff termination. | |
| Business Office Director | Responsible for reviewing assigned trainings on resident rights and performing monthly audits to ensure compliance. |
Inspection Report
Original Licensing
Census: 70
Capacity: 95
Deficiencies: 3
Jan 8, 2025
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the personal care home facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity status. Several citations were found and required correction, with plans of correction submitted and implemented.
Deficiencies (3)
| Description |
|---|
| Feces smeared in the bathroom sink of room 320. |
| No emergency telephone numbers posted on or by the telephone in room 320. |
| Fish in the main kitchen walk-in freezer was opened and unsealed. |
Report Facts
License Capacity: 95
Residents Served: 70
Secured Dementia Care Unit Capacity: 25
Residents Served in Secure Dementia Care Unit: 23
Current Residents: 11
Resident Support Staff: 0
Total Daily Staff: 102
Waking Staff: 77
Residents 60 Years or Older: 70
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 32
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
| Personal Care Director | Named in plan of correction for sanitary conditions and emergency telephone numbers. | |
| Dining Services Director | Named in plan of correction for food storage violation. |
Inspection Report
Monitoring
Census: 72
Capacity: 95
Deficiencies: 4
Jul 1, 2024
Visit Reason
The visit was a 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 for the facility.
Findings
The inspection identified several deficiencies including food contamination risk, medication storage and documentation issues, and improper use of PRN medication without documented behavioral interventions. Immediate corrective actions were taken and plans for ongoing compliance and monitoring were established.
Deficiencies (4)
| Description |
|---|
| Uncovered, unwrapped, undated container of ice cream stored in the pantry freezer of the memory care unit. |
| Resident glucometer readings were not accurately recorded. |
| The 'Controlled Substance Form' for a resident did not include the quantity of syringes received. |
| Resident was administered PRN medication for agitation without documentation of prior behavioral interventions. |
Report Facts
Residents Served: 72
License Capacity: 95
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 25
Current Hospice Residents: 6
Residents Age 60 or Older: 72
Residents with Mobility Need: 44
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 73
Capacity: 95
Deficiencies: 24
May 15, 2024
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including an unannounced full inspection on 05/15/2024 and 05/16/2024.
Findings
The inspection identified multiple deficiencies related to medication administration, resident abuse, criminal background checks, staff orientation and training, food safety, emergency procedures, fire safety, medical evaluations, medication storage and documentation, support plans, and staff training in dementia care. Plans of correction were accepted with proposed completion dates mostly by 06/30/2024 and implementation dates by 07/15/2024.
Deficiencies (24)
| Description |
|---|
| Resident records confidentiality breached by improper disposal of medication packages and unlocked medication room. |
| Resident abuse incident involving a caregiver causing a skin tear; staff member terminated. |
| Lack of criminal background checks on file for two staff members. |
| Staff person did not receive required fire safety orientation on first day. |
| Staff persons did not receive required annual training on medication self-administration and resident needs. |
| Poisonous materials (Clorox Urine Remover) unlocked and accessible to residents in Memory Care Unit. |
| Uncovered, unwrapped cheese stored in pantry refrigerator of Memory Care Unit. |
| Food stored on floor in Wellness room during medication pass. |
| Unlabeled, undated food items in pantry and freezer in Memory Care Unit and main kitchen. |
| Home's written emergency procedures lacked contact information for each resident’s designated person. |
| Fire drills only used two stairwells as exit routes; residents did not evacuate to designated meeting place during a fire drill. |
| Multiple resident medical evaluations lacked medical information pertinent to diagnosis and emergency treatment. |
| Resident unable to self-administer medications had medications left in room for later self-administration. |
| Prescription medications not administered by appropriate staff; medications left for resident to self-administer. |
| Morphine syringe found loose outside narcotics lock box on medication cart. |
| Medications stored with broken and taped blister packs. |
| Expired medications found on med carts and refrigerators, including Morphine and Lorazepam syringes. |
| Discrepancies in narcotic counts and glucometer readings recorded inaccurately. |
| Medication record for resident missing critical information including drug allergies, dosage, route, frequency, and purpose. |
| Medication administration times not recorded at time of administration; staff recorded initials prior to administration. |
| Resident refusal of medication not documented or reported as required. |
| Medication error not reported to resident representative or prescriber; expired medication administered. |
| Support plan for resident admitted to Secure Dementia Care Unit was completed late and lacked finalized date. |
| Staff working in Secure Dementia Care Unit lacked required annual dementia care training hours. |
Report Facts
License Capacity: 95
Residents Served: 73
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 24
Hospice Residents: 8
Staff Total Daily: 137
Staff Waking: 103
Expired Morphine Syringes: 15
Expired Lorazepam Syringes: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Medication Technician | Named in medication administration and confidentiality violations. |
| Staff member B | Involved in resident abuse incident and medication confidentiality violation. | |
| Staff member C | Involved in resident abuse incident. | |
| Staff member D | Involved in resident abuse incident. | |
| Staff member E | Medication Technician | Involved in resident abuse incident and medication training deficiencies. |
| Staff member F | Lack of criminal background check and training deficiencies. | |
| Staff member G | Lack of criminal background check. | |
| Staff person H | Did not receive required fire safety orientation on first day. | |
| Staff person I | Training deficiencies in medication self-administration and dementia care. |
Notice
Deficiencies: 0
Oct 31, 2023
Visit Reason
The document serves to notify Brightview Devon that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to the employee's education obtained outside the United States.
Findings
The waiver is granted with conditions including documentation of the employee's education equivalency and maintenance of records by the facility. The Department will review this waiver annually during inspections to ensure compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Harman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 95
Deficiencies: 4
Jul 20, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding allegations of resident abuse and staff qualifications.
Findings
The facility was found to have violations including failure to suspend a staff member involved in an alleged resident abuse incident without an approved supervision plan, direct care staff lacking required qualifications, and deficiencies in required annual training for direct care staff.
Complaint Details
The complaint involved an allegation that staff member B punched a resident in the arm. Staff member B was suspended but returned to work without an approved plan of supervision. The Department completed the investigation on 07/20/2023.
Deficiencies (4)
| Description |
|---|
| Failure to suspend staff member involved in alleged resident abuse without an approved plan of supervision. |
| Direct care staff person B does not have a U.S. 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, and personal care service needs during training year 2022. |
| Direct care staff person B did not receive required training in fire safety or the Older Adult Protective Services Act during training year 2022. |
Report Facts
Residents Served: 68
License Capacity: 95
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 6
Residents Age 60 or Older: 68
Residents with Mobility Need: 64
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 63
Capacity: 95
Deficiencies: 8
Sep 26, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of criminal background checks for delivery workers, unclean freezer and sticky floors in the kitchenette, use of a common towel, unlabeled leftover food, lint accumulation in dryer traps, lack of written notification to the fire department, and medication administration errors. All deficiencies had plans of correction submitted and were implemented by November 16, 2022.
Deficiencies (8)
| Description |
|---|
| Two delivery workers did not have criminal background checks on file and were not escorted by staff. |
| Freezer located in the kitchenette on the 2nd floor was unclean and stained by spills. |
| The floor in the kitchenette on the 2nd floor common area was sticky. |
| Use of a common towel in the bathroom of a resident's room; no sanitary means of hand drying available. |
| Containers of food in the freezer located on the 2nd floor kitchenette were unlabeled and undated. |
| Approximate 1/4 inch accumulation of lint in the traps of the dryers on the third floor. |
| No documentation of written notification to the local fire department regarding the home address, bedroom locations, and evacuation assistance. |
| Medication administration error: staff person administered medication without performing the 'five rights' (right resident, medication, dose, route, time). |
Report Facts
Residents Served: 63
License Capacity: 95
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 6
Residents Age 60 or Older: 63
Residents with Mobility Need: 26
Residents with Physical Disability: 2
Inspection Report
Follow-Up
Census: 67
Capacity: 95
Deficiencies: 2
May 4, 2022
Visit Reason
The inspection visit occurred as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Specific deficiencies related to resident support plan signatures and incident report documentation were addressed and corrected.
Deficiencies (2)
| Description |
|---|
| Resident #1 was unable to sign their support plan and the home did not make a notation on the signature page regarding this inability. |
| Resident #1's record did not include the incident report dated 4/25/22. |
Report Facts
License Capacity: 95
Residents Served: 67
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 4
Resident with Mental Illness: 1
Residents 60 Years or Older: 67
Residents with Mobility Need: 59
Total Daily Staff: 126
Waking Staff: 95
Inspection Report
Census: 70
Capacity: 95
Deficiencies: 0
Feb 4, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident, with multiple off-site inspection dates in February 2022.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on 02/04/2022, 02/08/2022, 02/11/2022, and 02/28/2022.
Report Facts
Total Daily Staff: 134
Waking Staff: 101
License Capacity: 95
Residents Served: 70
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 24
Residents Age 60 or Older: 70
Residents with Mobility Need: 64
Residents with Physical Disability: 61
Inspection Report
Renewal
Capacity: 95
Deficiencies: 0
Jul 7, 2021
Visit Reason
The document is a renewal application and license issuance for Brightview Devon Personal Care Home, confirming the facility's compliance and authorizing continued operation.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 95
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report
Renewal
Census: 57
Capacity: 95
Deficiencies: 14
Jun 14, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with unannounced full inspection visits on 06/14/2021 and 06/15/2021.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, unsecured poisonous materials accessible to residents, improper food storage and labeling, outdated emergency procedures, expired medications, uncalibrated glucometers, incomplete medication documentation, lack of resident education on medication refusal rights, incomplete preadmission screening forms, and untimely medical evaluations for residents in the secured dementia care unit. Plans of correction were accepted and documented for all deficiencies.
Deficiencies (14)
| Description |
|---|
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Poisonous materials including disinfectant spray and fluoride toothpaste were unlocked and accessible to residents not assessed as capable of safely using poisons. |
| Uncovered trays of frozen flounder and shrimp and uncovered frozen apple pies were stored in kitchen refrigerators/freezers. |
| Ice-cream tubs in the kitchen freezer were open with no lids. |
| Outdated or unlabeled food items including raw beef, cooked chicken breast, salad dressing, mayonnaise, chicken wings, and moldy strawberries were found in refrigerators. |
| Written emergency procedures had not been reviewed, updated, or submitted since 10/01/2019. |
| Expired medication Latanoprost Opht 0.005% was found in the medication cart for resident #1. |
| Glucometers for residents #2 and #3 were not calibrated to the correct date and time. |
| Narcotic medication counts for residents #1 and #2 were short by one pill each and administration was not documented on narcotics control log. |
| Resident #2's May medication administration record did not include initials of staff who administered Lorazepam on 05/02/2021 at 08:45 PM. |
| Resident #1 had not been educated on the right to refuse medication if a medication error is suspected. |
| Resident #3’s preadmission screening form did not include a determination that the resident's needs can be met by the home. |
| Resident #2 was admitted to the secured dementia care unit without a medical evaluation completed within 60 days prior to admission. |
Report Facts
License Capacity: 95
Residents Served: 57
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 21
Hospice Residents: 6
Total Daily Staff: 110
Waking Staff: 83
Inspection Report
Follow-Up
Census: 51
Capacity: 95
Deficiencies: 7
Jan 25, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident and regulatory violations at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing abuse, medication administration violations, and documentation deficiencies. Continued compliance was emphasized.
Deficiencies (7)
| Description |
|---|
| Resident #1 did not have a resident-home contract completed until 8/8/19. |
| Resident neglect and abuse involving Resident #1 and Resident #2 with administration of medications and physical harm. |
| Resident #1 administered medications to Resident #2 without proper authorization or training. |
| Medication administration record for Resident #2 lacked date, time, and staff initials for medications administered from 1/1/21 to 1/21/21. |
| Resident #2 was administered an unknown amount of prescribed medication Nuplazid at 2:15 A.M. |
| Resident #1 was not compensated for medication administration labor performed for Resident #2. |
| Preadmission screening form for Resident #1 was not completed timely. |
Report Facts
License Capacity: 95
Residents Served: 51
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 6
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 49
Residents Age 60 or Older: 51
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