Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 71
Capacity: 71
Deficiencies: 2
Jan 23, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and included a review of the submitted plan of correction to verify full implementation.
Findings
The submitted plan of correction was determined to be fully implemented, with two specific deficiencies related to combustible storage and key-locking devices corrected and ongoing compliance measures established.
Deficiencies (2)
| Description |
|---|
| Four oxygen cylinders were stored directly next to the PTAC unit, a heat source, in a resident room. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the gate to the outside of the Secured Dementia Care Unit courtyard. |
Report Facts
Residents Served: 71
Capacity: 71
Capacity: 24
Residents Served: 21
Total Daily Staff: 113
Waking Staff: 85
Residents Age 60 or Older: 70
Residents with Mobility Need: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Director | Named in relation to corrective actions for combustible storage deficiency. | |
| Maintenance Director | Named in relation to corrective actions for combustible storage and key-locking devices deficiencies. |
Inspection Report
Monitoring
Census: 65
Capacity: 90
Deficiencies: 1
Jul 18, 2024
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes at the facility.
Findings
The submitted plan of correction related to a medication record deficiency was found to be fully implemented. The facility added a dosage column to the Medication Administration Record (MAR) and conducted staff training to ensure proper documentation of medication dosages.
Deficiencies (1)
| Description |
|---|
| Medication record did not have space to document dosage units given to Resident #1 as ordered, resulting in undocumented medication administration. |
Report Facts
License Capacity: 90
Residents Served: 65
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 19
Residents 60 Years or Older: 65
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health Services Director | Took immediate action to add dosage column to MAR and conducted medication record dosage documentation in-service |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 40
Deficiencies: 1
Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/15/2023.
Findings
The submitted plan of correction was determined to be fully implemented. One deficiency was found related to a resident's support plan not being updated to reflect wound care and repositioning needs as required.
Complaint Details
The inspection was complaint-related and incident-driven. The plan of correction was accepted and fully implemented by 12/04/2023.
Deficiencies (1)
| Description |
|---|
| Resident #1's support plan was not updated to reflect wound care for a sacral wound and repositioning every 2 hours as per hospice requirements. |
Report Facts
License Capacity: 40
Residents Served: 29
Current Residents in Hospice: 16
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Renewal
Census: 68
Capacity: 90
Deficiencies: 24
Oct 2, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation of the Personal Care Home facility.
Findings
Multiple violations were found including failure to immediately report suspected abuse, lack of proper supervision plans for alleged abuse, delayed incident reporting, inadequate training for direct care staff, unsafe storage of poisonous materials, and deficiencies in resident medical evaluations and support plans.
Deficiencies (24)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report incident or condition to the Department within 24 hours. |
| Direct care staff did not receive required medication self-administration training. |
| Direct care staff did not receive required fire safety training. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| Furniture and equipment not in good repair; clogged bathroom sink. |
| Food stored on the floor. |
| Freezer temperature above required level. |
| Expired emergency food in resident storage. |
| Written emergency procedures not submitted annually to local emergency management agency. |
| Fire drill record missing time of drill. |
| Alternate exit routes not used during fire drills. |
| Fire drills routinely held in last week of the month. |
| Resident medical evaluation missing body positioning and movement stimulation. |
| First aid kit in transport vehicle missing eye covering. |
| Medication in home without current order. |
| Original container for prescription medication not labeled with correct dosage instructions. |
| Medications and medical equipment not safely stored or available as prescribed. |
| Resident assessments not completed annually or as required. |
| Resident support plans missing documentation of medical, dental, vision, hearing, mental health or behavioral care services. |
| Resident support plan not signed by assessor. |
| Resident medical evaluation missing diagnosis of dementia and need for secured dementia care unit. |
| Support plan for secured dementia care unit admission not developed or documented within required timeframe. |
Report Facts
License Capacity: 90
Residents Served: 68
Residents Served in Secured Dementia Care Unit: 18
Staffing Hours: 104
Waking Staff: 78
Deficiency Counts: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letters and communications. |
Inspection Report
Renewal
Census: 68
Capacity: 90
Deficiencies: 25
Oct 2, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation of the facility.
Findings
Multiple violations were found related to resident abuse reporting, staff training, medication management, emergency preparedness, and support plan documentation. The facility was issued a first provisional license due to these violations and required to submit plans of correction.
Deficiencies (25)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report incident to the Department within 24 hours. |
| Resident contract not signed timely. |
| Resident was physically abused resulting in bruising. |
| Direct care staff did not receive required medication self-administration training. |
| Direct care staff did not receive required fire safety training. |
| Poisonous materials were not kept locked and accessible to residents. |
| Furniture and equipment not in good repair (clogged bathroom sink). |
| Food stored on the floor. |
| Food requiring refrigeration not stored at or below required temperatures. |
| Outdated or spoiled emergency food in resident storage. |
| Written emergency procedures not submitted annually to local emergency management agency. |
| Fire drill records incomplete (missing time). |
| Alternate exit routes not used during fire drills. |
| Fire drills routinely held in last week of the month. |
| Resident medical evaluation missing required elements (body positioning and movement stimulation). |
| First aid kit in transport vehicle missing eye covering. |
| Medication in home without current order. |
| Medication storage and availability issues (missing PRN meds, uncalibrated glucometer). |
| Resident assessments not completed timely or updated as required. |
| Resident support plans missing documentation of medical, dental, vision, hearing, mental health or behavioral care services. |
| Resident support plan not signed by assessor. |
| Resident medical evaluation missing documentation of need for secured dementia care unit. |
| Support plan for secured dementia care unit admission not developed or documented timely. |
Report Facts
License Capacity: 90
Residents Served: 68
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 104
Waking Staff: 78
Deficiency Counts: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter regarding provisional license issuance. |
| Health Services Director | Named in multiple findings related to abuse reporting, medication management, medical evaluations, and support plan corrections. | |
| Wellspring Village Director | Named in findings related to supervision plans, abuse reporting, poisonous materials, and support plan corrections. | |
| Personal Care Director | Named in findings related to abuse training, support plan corrections, and medication management. | |
| Business Office Director | Named in findings related to contract signatures and staff training audits. | |
| Maintenance Director | Named in findings related to fire drills, furniture repair, emergency procedures, and storage compliance. | |
| Medication Technician | Named in findings related to medication audits and removal of discontinued medications. | |
| Wellness Nurse | Named in findings related to medication audits and medical evaluations. | |
| Vibrant Living Director | Named in finding related to first aid kit compliance in transport vehicle. |
Inspection Report
Plan of Correction
Census: 63
Capacity: 90
Deficiencies: 1
Jun 14, 2023
Visit Reason
The visit was a complaint and incident investigation conducted on June 14, 2023, to review the facility's compliance and the implementation status of a previously submitted plan of correction.
Findings
The facility failed to fully implement the plan of correction related to a written incident report violation where an incident involving a staff member allegedly placing a pillow over a resident's face was not reported to the department within the required 24-hour timeframe.
Complaint Details
The inspection was complaint-related and involved an incident where Staff Member A allegedly placed a pillow over the face of Resident #1 on 6/1/23 at approximately 5:30 A.M. The incident was reported to the home on 6/2/23 at 11:30 P.M., but the home did not report it to the department until 6/3/23, which was outside the required 24-hour reporting window. The plan of correction was accepted but not fully implemented as of the follow-up on October 2, 2023.
Deficiencies (1)
| Description |
|---|
| The home did not report an incident involving a staff member allegedly placing a pillow over the face of a resident within 24 hours as required. |
Report Facts
License Capacity: 90
Residents Served: 63
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 16
Current Hospice Residents: 1
Residents 60 Years or Older: 61
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 34
Total Daily Staff: 97
Waking Staff: 73
Inspection Report
Follow-Up
Census: 65
Capacity: 90
Deficiencies: 6
May 1, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to multiple deficiencies including resident abuse reporting, direct care staff training, medication administration, additional resident assessments, and support plan documentation. Continued compliance is required.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act. |
| Direct care staff person provided unsupervised ADL services without completing and passing the Department-approved direct care training and competency test. |
| Staff person did not place medication in resident’s hand, mouth, or other route as ordered, leaving medication unattended for a resident not assessed as capable of self-administration. |
| Resident assessment did not include evaluation for agitation and confusion despite resident exhibiting these symptoms. |
| Resident support plan did not document medical diagnosis from medical evaluation and how the need would be met. |
| Resident refused to sign support plan and the facility failed to document the refusal or inability to sign. |
Report Facts
License Capacity: 90
Residents Served: 65
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 3
Residents Age 60 or Older: 63
Residents with Intellectual Disability: 2
Residents with Mobility Need: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person C | Named in medication administration deficiency for not administering medication as ordered | |
| Personal Care Director | Involved in plan of correction implementation and staff education | |
| Health Service Director | Involved in plan of correction implementation, staff education, and monitoring service plans |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 90
Deficiencies: 2
Jan 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with resident care requirements and assess the submitted plan of correction.
Findings
The facility was found to have deficiencies related to resident assistance with activities of daily living, specifically failure to provide two-person assistance during transfers as required by the resident's assessment. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was accepted and determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1 did not receive required two-person assistance when transferring, only one staff assisted. |
| Resident #1’s assessment did not include the requirement for two-person assistance with transferring. |
Report Facts
Residents Served: 69
License Capacity: 90
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 2
Residents Age 60 or Older: 68
Residents with Intellectual Disability: 2
Residents with Mobility Need: 56
Inspection Report
Follow-Up
Census: 48
Capacity: 90
Deficiencies: 3
Aug 3, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with a follow-up review of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies involved incomplete resident assessments and support plans, which were addressed through updated documentation and ongoing audits.
Deficiencies (3)
| Description |
|---|
| Resident #1's assessment did not include the Resident's need of agitation and aggression. |
| Resident #2's most recent assessment was not completed following an altercation with another resident. |
| Resident #2's support plan did not indicate how the home plans to address hallucinations and delusions. |
Report Facts
License Capacity: 90
Residents Served: 48
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Residents with Mobility Need: 40
Residents Age 60 or Older: 47
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 67
Capacity: 90
Deficiencies: 3
May 25, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for the facility.
Findings
The inspection identified three deficiencies: uncovered dumpsters outside the home, lack of documentation for an annual fire safety inspection and fire drill, and meal service times exceeding allowed hours between meals. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (3)
| Description |
|---|
| Two dumpsters located outside were not covered with their lids. |
| The home could not provide documentation showing a fire safety inspection conducted by a fire safety expert. |
| The home serves dinner at 4:30 pm daily; however, breakfast is served at 9:00 am daily, exceeding the allowed hours between meals. |
Report Facts
License Capacity: 90
Residents Served: 67
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 5
Residents 60 Years or Older: 65
Residents with Intellectual Disability: 1
Residents with Mobility Need: 40
Total Daily Staff: 107
Waking Staff: 80
Inspection Report
Follow-Up
Census: 62
Capacity: 90
Deficiencies: 3
Apr 13, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/13/2022 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The inspection found that the submitted plan of correction was fully implemented, including removal of unsecured poisonous materials and completion of required training. Deficiencies related to locking poisonous materials and support plan signatures were addressed with documented corrective actions.
Deficiencies (3)
| Description |
|---|
| Unsecured poisonous materials were accessible to residents in the Wellspring Secure Dementia Care Unit, including unlocked medication closets and hazardous sprays. |
| Resident #1 participated in the development of the support plan but did not sign it initially. |
| Resident #2's initial support plan was not completed within 72 hours of admission to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 90
Residents Served: 62
Capacity of Secured Dementia Care Unit: 24
Residents Served in SDCU: 19
Current Hospice Residents: 6
Total Daily Staff: 102
Waking Staff: 77
Notice
Capacity: 90
Deficiencies: 0
Jul 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Brightview East Norriton, confirming receipt of the renewal application and advising of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining the requirement for an annual inspection.
Report Facts
Maximum capacity: 90
Secure Dementia Care Unit capacity: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 59
Capacity: 90
Deficiencies: 4
May 25, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review on May 25 and 26, 2021.
Findings
The facility was found to have deficiencies related to privacy signage, resident personal equipment maintenance, emergency procedures for inoperable smoke detectors, and posting of weekly menus. The submitted plan of correction was determined to be fully implemented upon follow-up.
Deficiencies (4)
| Description |
|---|
| No signs indicating that images were being recorded at the main entrance of the home. |
| Resident's personal equipment was in disrepair with batteries not working properly and numbers distorted and incomplete. |
| The home's emergency procedures did not indicate what procedures will be implemented when a smoke detector or fire alarm is inoperable. |
| Menus for the current week and following week were not posted as required. |
Report Facts
License Capacity: 90
Residents Served: 59
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 3
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Complaint Investigation
Census: 52
Capacity: 90
Deficiencies: 2
Jan 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation, involving multiple off-site review dates to assess compliance and plan of correction implementation.
Findings
The facility was found to have deficiencies related to staff orientation and training, specifically that a staff person did not receive required fire safety orientation until after their first day and did not complete training on emergency medical plan and reporting of incidents within 40 scheduled work hours. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was triggered by a complaint and was conducted as a partial, unannounced review over multiple dates. The complaint was related to staff training and orientation deficiencies.
Deficiencies (2)
| Description |
|---|
| Staff person did not receive orientation on fire safety and emergency preparedness until after the first day of work. |
| Staff person did not complete training on emergency medical plan and reporting of reportable incidents and conditions within 40 scheduled work hours. |
Report Facts
Licensed Capacity: 90
Residents Served: 52
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 22
Total Daily Staff: 83
Waking Staff: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed the letter regarding plan of correction implementation |
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