Inspection Reports for Bristol House Memory Care
2527 Bristol Rd, Warrington, PA 18976, PA, 18976
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Inspection Report
Renewal
Census: 39
Capacity: 48
Deficiencies: 23
Sep 16, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post current license summary, missing quality management and resident council meeting minutes, incomplete criminal background checks for hospice staff, incomplete staff contact lists, insufficient staff training hours and topics, unsecured poisonous materials, missing emergency telephone numbers, furniture and equipment issues, incomplete emergency procedure submissions, lack of fire department notification, unsecured fire extinguishers, delayed fire extinguisher inspections, prolonged evacuation times, incomplete medical evaluations, missing posted menus, medication storage and documentation errors, unsigned support plans, lack of written approvals for locking devices, missing manufacturer statements for locking systems, and inadequate dementia care training for staff.
Deficiencies (23)
| Description |
|---|
| License inspection summary was not posted in a conspicuous and public place in the home. |
| Missing resident council meeting minutes and quality management meeting minutes. |
| No criminal background checks for Serenity hospice staff. |
| Administrator did not have a complete staff list including agency staff. |
| Direct care staff person B received only 2 hours of annual training in 2024, less than required 12 hours. |
| Direct care staff person B did not receive required training topics including medication self-administration and care for residents with mental illness. |
| Direct care staff person B did not receive required annual training topics including fire safety, emergency preparedness, resident rights, and falls prevention. |
| Poisonous materials were unlocked, unattended, and accessible to residents not assessed capable of safe use. |
| No emergency telephone numbers posted on or by telephones in resident rooms. |
| Resident did not have a toilet paper holder in their bathroom. |
| No toilet paper was available in resident bathroom at time of inspection. |
| Home could not provide proof that written emergency procedures had been submitted to local emergency management. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Fire extinguishers throughout building were not kept locked, allowing resident access and removal of inspection tags. |
| Fire extinguisher near resident rooms did not have an inspection tag. |
| Evacuation times during fire drills exceeded maximum safe evacuation time specified by fire safety expert. |
| Resident medical evaluations lacked documentation of special health or dietary needs and need for wheelchair. |
| Menus for two consecutive weeks were not posted in designated dining neighborhoods. |
| Medication administration record documented incorrect blood glucose reading compared to glucometer. |
| Residents participated in support plan development but did not sign the support plans. |
| No written approval from Department of Labor and Industry, Department of Health, or local building authority for key locking devices and electronic card systems on exit doors from Secure Dementia Care Unit. |
| No manufacturer statement verifying magnetic locking system releases upon fire alarm activation, power failure, or lock release device operation. |
| Direct care staff persons working in Secure Dementia Care Unit had zero or insufficient dementia care training hours during 2024 training year. |
Report Facts
Residents Served: 39
License Capacity: 48
Total Daily Staff: 78
Waking Staff: 59
Current Hospice Residents: 11
Residents Age 60 or Older: 38
Residents with Mobility Need: 39
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Follow-Up Date: Oct 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Direct care staff person | Named in multiple findings related to insufficient training hours and topics |
| Staff person C | Direct care staff person | Named in finding related to insufficient dementia care training |
| Executive Director | Named in multiple findings related to corrective actions, education, and compliance oversight | |
| Director of Nursing | Named in corrective action education and audits | |
| Business Office Manager | Named in corrective action education and audits | |
| Business Office Assistant | Named in corrective action education and audits | |
| Director of Activities | Named in corrective action education | |
| Maintenance Person | Named in corrective action education and audits related to fire extinguishers and room sweeps | |
| Resident Care Coordinator | Named in education related to poisonous materials removal |
Inspection Report
Follow-Up
Census: 34
Capacity: 48
Deficiencies: 6
Jan 15, 2025
Visit Reason
The visit occurred as a follow-up review on January 15, 2025, to assess the implementation status of the plan of correction submitted for the June 26, 2024 inspection.
Findings
The submitted plan of correction for the June 26, 2024 inspection was determined to be not fully implemented as of the January 15, 2025 review. Several deficiencies related to record confidentiality, locking poisonous materials, trash receptacles, medical evaluations, preadmission screening, and admission support plans remain uncorrected.
Deficiencies (6)
| Description |
|---|
| Residents' task sheets containing care needs, skin checks, and shower schedules were left unlocked, unattended, and accessible to residents and visitors. |
| Poisonous materials including various toothpastes and hair spray were unlocked, unattended, and accessible to residents not assessed as capable of safely using or avoiding poisons. |
| An overflowing, uncovered, and unattended trash can with breakfast waste was found in the Gold Finch kitchen. |
| Resident #4's medical evaluation was incomplete and not reviewed for the necessity of a secure dementia unit. |
| Resident #1, #2, and #4 had incomplete or improperly documented written cognitive preadmission screenings. |
| Resident #4's initial admission support plan was completed late, not within the required 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 48
Residents Served: 34
Staffing Hours: 68
Waking Staff: 51
Current Hospice Residents: 11
Inspection Report
Renewal
Census: 32
Capacity: 48
Deficiencies: 26
Oct 17, 2024
Visit Reason
The inspection was an unannounced renewal and provisional review of the Bristol House Memory Care facility conducted on 10/17/2024.
Findings
The inspection identified multiple deficiencies including missing resident signatures on contracts, incomplete criminal background checks, lack of CPR/First Aid certified staff on certain shifts, insufficient annual training for staff, inadequate policies for bedside mobility devices, unsecured poisonous materials, missing emergency telephone numbers, incomplete first aid kits, improper food thawing procedures, incomplete emergency preparedness plans and procedures, medication storage and administration issues, incomplete resident support plans, missing resident photographs, and lack of dementia care training for staff. Plans of correction were accepted and implemented by 02/14/2025.
Deficiencies (26)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Staff member did not have a required FBI background check due to lack of Pennsylvania residency for two years. |
| No staff person certified in first aid and CPR was present during certain shifts. |
| Direct care staff person D received only 5.75 hours of annual training in 2023, less than the required 12 hours. |
| Direct care staff person D did not receive required training on medication self-administration, dementia care, and safe management techniques in 2023. |
| The home lacked policies and procedures for use of bedside mobility devices; residents #2 and #3 used such devices without proper documentation. |
| Resident #2 had a bedside mobility device exceeding FDA guidelines and was covered with a loose pillowcase. |
| Poisonous materials were found unsecured and accessible to residents, including bleach and deodorant with poison warnings. |
| Emergency telephone numbers were not posted by the telephone in the Gold Finch nurse station. |
| The first aid kit in the kitchen was missing antiseptic and tweezers. |
| Food was thawed improperly in the kitchen service sink without water. |
| Administrator did not have the emergency preparedness plan for the local municipality. |
| The home's written emergency procedures lacked required elements including contact information for residents' designated persons and emergency management agencies. |
| The home's written emergency procedures had not been submitted annually to the local emergency management agency. |
| An opened bottle of eye drops was kept beyond the manufacturer's recommended discard date. |
| Resident #4's medication administration record did not document insulin doses administered on multiple dates. |
| Resident #6 was not administered prescribed eye drops due to medication unavailability. |
| Resident #4's medication administration record inaccurately documented medications as administered when resident refused them. |
| Resident #5's narcotic medication was not signed out on the narcotics control record despite being administered. |
| Resident #7 was not administered prescribed medication on 10/07/2024. |
| Staff person D administered medications without a current Department-approved medication administration course. |
| Staff persons D and F administered insulin and checked blood glucose without completing required diabetes patient education within the past 12 months. |
| Resident #2's initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
| Support plans for residents #2 and #3 did not address use of bedside mobility devices and half-rails on the bed. |
| Direct care staff person D did not have required dementia care training during the 2023 training year. |
| Resident #3's record did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 48
Residents Served: 32
Staffing Hours: 64
Waking Staff: 48
Residents with Mobility Need: 32
Current Hospice Residents: 8
Deficiencies Cited: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person D | Direct Care Staff Person | Named in multiple findings related to insufficient training, medication administration, and diabetes education. |
| Staff Person A | Named in criminal background check deficiency. | |
| Staff Person E | Named in medication administration documentation deficiencies. | |
| Staff Person F | Named in medication administration training and diabetes education deficiencies. | |
| Resident Care Coordinator | Named in multiple corrective actions related to medication administration, audits, and training. | |
| Administrator | Named in multiple corrective actions and education efforts. | |
| Business Office Manager | Named in multiple corrective actions and audits. | |
| Director of Nursing | Named in oversight deficiencies and corrective actions. |
Inspection Report
Follow-Up
Census: 35
Capacity: 48
Deficiencies: 18
Aug 15, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection to verify the implementation of a previously submitted plan of correction for Bristol House Memory Care.
Findings
The inspection found multiple deficiencies related to access to records, contract signatures, criminal background checks, staff qualifications, training records, medication storage and administration, fire drill scheduling, and resident medical evaluations. The facility has implemented corrective actions and training to address these issues, with ongoing audits and monitoring planned.
Deficiencies (18)
| Description |
|---|
| Delayed access to records requested by an agent of the Department. |
| Resident-home contracts were not signed by residents with no indication of opportunity to sign. |
| Staff hired without proper criminal background checks including FBI clearance. |
| Staff hired without timely completion of background checks. |
| Administrator lacks required qualifications or licenses. |
| Direct care staff person lacks high school diploma, GED, or active nurse aide registry status. |
| Administrator maintains incomplete staff list. |
| Incomplete training records for direct care staff. |
| Poisonous materials were unlocked and accessible to residents. |
| Staff person did not know the location of the first aid kit. |
| Food stored unsealed and partially open, risking contamination. |
| Fire drills routinely held at the same times and days, not staggered as required. |
| Medication blister pack foil punctured and taped over with pill still inside. |
| Over-the-counter medication not labeled with resident's name. |
| Medical equipment (glucometer) not calibrated to correct date and time. |
| Medication administered later than prescribed time. |
| Medication administration training record incomplete for staff person. |
| Resident medical evaluation not completed within 60 days prior to admission to secured dementia care unit. |
Report Facts
Residents served: 35
License capacity: 48
Total daily staff: 70
Waking staff: 53
Current residents in hospice: 11
Residents 60 years or older: 35
Residents with mobility need: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person C | Named in criminal background check violation for missing FBI clearance and residency acknowledgment | |
| Staff person D | Named in violations for lacking high school diploma/GED and incomplete background check timing | |
| Staff person E | Administrator | Named in violations for lacking required qualifications and maintaining incomplete staff list |
| Staff person F | Named in violations for not knowing first aid kit location and incomplete medication training record | |
| Executive Director | Responsible for implementing corrective actions and training | |
| Director of Nursing | Responsible for training, audits, and corrective actions related to medication and first aid | |
| Business office manager | Responsible for staff hiring checklist and record-keeping improvements | |
| Resident care coordinator | Involved in audits and monitoring of resident care and storage of personal items |
Inspection Report
Renewal
Census: 35
Capacity: 48
Deficiencies: 17
Aug 15, 2024
Visit Reason
The inspection was a provisional, monitoring visit conducted on August 15, 2024, to review compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple deficiencies including delayed access to records, unsigned resident contracts, incomplete criminal background checks, staff qualification issues, unsecured poisonous materials, medication storage and administration errors, and incomplete staff training. Plans of correction were accepted and implemented by February 14, 2025.
Deficiencies (17)
| Description |
|---|
| Delayed access to records requested by Department agents. |
| Resident-home contracts not signed by residents. |
| Staff hired without completed criminal background checks and FBI clearance. |
| Administrator lacked required qualifications. |
| Direct care staff lacked required high school diploma, GED, or registry status. |
| Incomplete staff list missing some employees. |
| Incomplete training records for direct care staff. |
| Poisonous materials unlocked and accessible to residents. |
| Staff unaware of first aid kit location. |
| Food stored unsealed and partially open. |
| Fire drills routinely held at same times and days. |
| Medication packaging compromised with punctured blister packs. |
| OTC medication not labeled with resident's name. |
| Glucometer not calibrated to correct date/time. |
| Medications administered late or not as prescribed. |
| Medication administration training records incomplete. |
| Resident medical evaluation not completed within required timeframe. |
Report Facts
Deficiencies cited: 17
Residents served: 35
License capacity: 48
Total daily staff: 70
Waking staff: 53
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 1
Jul 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection type.
Findings
The facility was found deficient in involving the resident or the resident’s designated person in the development and revisions of the support plan. A plan of correction was submitted and fully implemented by 09/03/2024.
Complaint Details
The visit was complaint-related as indicated by the reason for inspection. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (1)
| Description |
|---|
| Neither the resident nor the resident's designated person was involved in the development of the support plan. |
Report Facts
License Capacity: 48
Residents Served: 35
Staffing Hours - Total Daily Staff: 70
Staffing Hours - Waking Staff: 53
Audit Percentage: 25
Inspection Report
Renewal
Census: 38
Capacity: 48
Deficiencies: 32
Feb 22, 2024
Visit Reason
The inspection was a renewal and provisional inspection of Bristol House Memory Care to assess compliance with 55 Pa. Code Chapter 2600 regulations for Personal Care Homes.
Findings
The inspection identified multiple deficiencies including issues with staff qualifications, training, posting of regulations, quality management plan, sanitary conditions, fire drill documentation, emergency medical plan, medication storage, and resident care documentation. Plans of correction were accepted with various proposed completion dates.
Deficiencies (32)
| Description |
|---|
| Labels identifying resident medications were unsecured and visible outside the medication cart. |
| Staff person hired without proper Pennsylvania residency and FBI clearance. |
| Insufficient direct care staffing hours provided for residents with mobility needs. |
| Less than 75% of personal care service hours provided during waking hours. |
| Staff person did not receive required fire safety orientation on first day. |
| Ancillary staff person lacked general orientation to job functions. |
| Direct care staff person provided unsupervised ADL services without completing required training and competency test. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| Bathroom floor stained with feces. |
| Trash can in kitchenette was full, uncovered, and unattended. |
| Resident medication (Acetaminophen suppositories) not available in the home. |
| Resident initial assessment not completed within 15 days of admission. |
| Resident cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit. |
| No copy of 2600 chapter regulations posted in a conspicuous and public place. |
| No quality management plan established or implemented. |
| Direct care staff person lacked required high school diploma, GED, or active registry status. |
| Direct care staff person did not receive required annual training on medication self-administration, dementia care, infection control, and safe management techniques. |
| Direct care staff person did not receive required annual training on Older Adult Protective Services Act and falls and accident prevention. |
| Poisonous materials (toothpaste) unlocked and accessible to residents not assessed as safe to use them. |
| No form of hand drying available in ladies’ bathroom. |
| Trash cans in kitchen were not covered. |
| Residents did not have access to operable lamps or lighting at bedside. |
| Towels and washcloths not accessible to resident in bathroom. |
| Food stored on floor in emergency supply area. |
| Home's emergency procedures did not indicate actions when smoke detector or fire alarm is inoperable. |
| Fire drill records incomplete, missing key information such as evacuation time, exit route, number of residents and staff participating, and alarm status. |
| No fire drill conducted during sleeping hours for several months. |
| No written emergency medical plan available. |
| Resident's glucometer not calibrated to correct time. |
| Resident cognitive preadmission screening incomplete and not timely. |
| Staff persons providing direct care to residents with dementia lacked documentation of required dementia care training. |
| Odor of urine present in resident room. |
Report Facts
License Capacity: 48
Residents Served: 38
Residents Served: 47
Residents Served: 39
Current Residents: 13
Total Daily Staff: 94
Waking Staff: 71
Total Daily Staff: 76
Waking Staff: 57
Total Daily Staff: 78
Waking Staff: 59
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Census at Inspection: 45
Inspection Report
Provisional
Census: 47
Capacity: 48
Deficiencies: 32
Dec 27, 2023
Visit Reason
The inspection was conducted as a provisional and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes, including follow-up on previous deficiencies and plan of correction submissions.
Findings
Multiple deficiencies were found including issues with record confidentiality, criminal background checks, staffing hours, orientation and training of staff, locking poisonous materials, sanitary conditions, trash receptacles, medication storage, resident assessments, fire safety, emergency procedures, and staff training. Several deficiencies were repeated from prior inspections. Plans of correction were submitted with proposed completion dates, but many were not implemented as of the inspection date.
Deficiencies (32)
| Description |
|---|
| Labels identifying resident medications for residents #1, #2, #3, and #4 were located outside the medication cart, unsecured and available to be viewed by passersby. |
| Staff person A was hired without proper FBI clearance and was not a Pennsylvania resident for two years. |
| Direct care staffing hours were below the required minimum for residents with mobility needs. |
| Less than 75% of personal care service hours were provided during waking hours. |
| Staff person A did not receive required fire safety orientation on the first day of work. |
| Ancillary staff person A did not have a general orientation to her specific job functions. |
| Direct care staff person B provided unsupervised ADL services without completing required training and competency test. |
| Poisonous materials were unlocked and accessible to residents, including lotion with poison warning. |
| Bathroom floor in a resident's room was stained with feces residue. |
| Trash can in kitchenette was full, uncovered, and unattended. |
| Resident #6's prescribed Acetaminophen suppositories were not available in the home. |
| Resident #7's initial assessment was not completed within 15 days of admission. |
| Resident #7's written cognitive preadmission screening was completed late, not within 72 hours prior to admission. |
| No copy of the 2600 chapter regulations was posted in a conspicuous and public place in the home. |
| The home did not have a quality management plan. |
| Direct care staff person A did 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 annual training on medication self-administration, dementia care, infection control, and safe management techniques. |
| Direct care staff person B did not receive training on the Older Adult Protective Services Act or falls and accident prevention. |
| Toothpaste with poison warnings was unlocked and accessible to residents. |
| No form of hand drying was available in the ladies’ bathroom. |
| Trash cans in the kitchen were not covered. |
| Residents #1 and #2 did not have access to operable lamps or lighting at bedside. |
| Towels and washcloths were not accessible to resident #1 in the bathroom. |
| Food was stored on the floor in the emergency supply area. |
| The home's emergency procedures did not indicate actions to be taken when smoke detectors or fire alarms are inoperable. |
| Fire drill records did not include required details such as evacuation time, exit route, number of residents and staff participating, problems encountered, and operability of alarms. |
| No fire drill was conducted during sleeping hours between April and December 2023. |
| The home did not have a written emergency medical plan. |
| Resident #3's glucometer was not calibrated to the correct time. |
| Resident #2's cognitive preadmission screening was completed more than 72 hours prior to admission and was incomplete. |
| The home did not have documentation that staff persons A and B received six hours of dementia care training. |
| On 2024, there was an odor of urine in a resident's room that lessened but was still present by 1:00 pm. |
Report Facts
License Capacity: 48
Residents Served: 47
Residents Served: 38
Residents Served: 39
Total Daily Staff: 94
Waking Staff: 71
Total Daily Staff: 76
Waking Staff: 57
Total Daily Staff: 78
Waking Staff: 59
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Mandated Correction Date: 5
Inspection Report
Provisional
Census: 47
Capacity: 48
Deficiencies: 13
Dec 27, 2023
Visit Reason
The inspection was conducted as a provisional and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple deficiencies were found including issues with record confidentiality, criminal background checks, staffing hours, orientation and training of staff, locking poisonous materials, sanitary conditions, trash receptacles, medication storage, resident assessments, fire safety procedures, and emergency plans. Plans of correction were submitted with some deficiencies not yet implemented as of the report date.
Deficiencies (13)
| Description |
|---|
| Labels identifying resident medications were unsecured and visible outside the medication cart. |
| Staff person hired without proper FBI clearance and not a Pennsylvania resident for two years. |
| Insufficient direct care staffing hours provided for residents with mobility needs. |
| Less than 75% of personal care service hours provided during waking hours. |
| Staff person did not receive required fire safety orientation on first day. |
| Ancillary staff person did not have general orientation to job functions. |
| Direct care staff person provided unsupervised ADL services without completing required training and competency test. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| Bathroom floor stained with feces. |
| Trash can in kitchenette was full, uncovered, and unattended. |
| Resident medication (Acetaminophen suppositories) not available in the home. |
| Resident initial assessment not completed within 15 days of admission. |
| Resident cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit. |
Report Facts
License Capacity: 48
Residents Served: 47
Staffing Hours: 94
Waking Staff Hours: 71
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Correction Deadline Days: 5
Residents Served: 38
Total Daily Staff: 76
Waking Staff: 57
Residents Served: 39
Total Daily Staff: 78
Waking Staff: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to criminal background check, direct care staff qualifications, and dementia care training. | |
| Staff person B | Named in findings related to direct care training, annual training topics, dementia care training, and orientation. | |
| Executive Director | Named in multiple findings as responsible for retraining staff, auditing, and implementing corrective actions. | |
| Director of Nursing | Named in multiple findings as responsible for staff training, audits, and corrective actions. | |
| Resident Care Coordinator | Named in findings related to staffing and training oversight. | |
| Business Office Manager | Named in findings related to audits and quality management plan. |
Inspection Report
Follow-Up
Census: 46
Capacity: 48
Deficiencies: 3
Nov 6, 2023
Visit Reason
The visit was a follow-up inspection to verify that the submitted plan of correction for previous deficiencies was fully implemented.
Findings
The inspection found that the submitted plan of correction was fully implemented, with specific corrective actions taken for deficiencies related to toilet paper availability and medical evaluation documentation.
Deficiencies (3)
| Description |
|---|
| No toilet paper was provided for the 2 toilets in the bathroom located in the main hallway. |
| Resident medical evaluations were incomplete, missing information such as the ability to self-administer medications, special health or dietary needs, and immunization history. |
| Resident admitted to the Secured Dementia Care Unit had incomplete medical evaluation documentation. |
Report Facts
License Capacity: 48
Residents Served: 46
Staffing Hours: 92
Staffing Hours: 69
Inspection Report
Complaint Investigation
Census: 45
Capacity: 48
Deficiencies: 4
Jul 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on July 6, 2023, to assess compliance with regulations at Bristol House Memory Care.
Findings
The inspection found multiple medication-related violations including discontinued medication still present, incomplete controlled substance records, failure to record medication administration times, and failure to follow prescriber's orders. Plans of correction were accepted but not implemented as of October 2, 2023.
Complaint Details
The inspection was complaint-driven and unannounced. The report does not explicitly state substantiation status.
Deficiencies (4)
| Description |
|---|
| Discontinued medication (Ivermectin) was found in the medication cart after discontinuation date. |
| Controlled substance record for Morphine did not include date received or received by info; quantity received was incorrect. |
| Medication administration record for Lorazepam was not signed out and medication not administered as prescribed on 06/12/2023. |
| Failure to follow prescriber's orders regarding Lorazepam administration. |
Report Facts
License Capacity: 48
Residents Served: 45
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Number of Violations Subject to Fine: 3
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Monitoring
Census: 47
Capacity: 48
Deficiencies: 11
May 15, 2023
Visit Reason
The inspection was a monitoring visit conducted on May 15, 2023, to review compliance with licensing regulations and follow up on previous deficiencies.
Findings
Multiple violations were found related to staff qualifications, orientation, medical evaluations, medication administration, storage procedures, and documentation. Plans of correction were submitted but not fully implemented as of August 9, 2023.
Deficiencies (11)
| Description |
|---|
| No verification of a Criminal Background Check provided for caregiver, Staff Person A. |
| Staff Person B, a direct care provider, 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 on fire safety and emergency preparedness topics on first day of work. |
| Staff person A did not complete training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reportable incidents. |
| Poisonous materials (Head & Shoulders shampoo) were unlocked, unattended, and accessible to residents. |
| Resident 1's medical evaluation did not include medical diagnoses, including any physical or mental disabilities. |
| The glucometer log for Resident 4 lists a reading not present on the glucometer device. |
| Staff person C administered medications without completing the Department-approved medication administration course. |
| Resident 2 was administered Lorazepam to control behaviors, which may constitute chemical restraint. |
| Resident #3 did not sign the support plan dated 4/2/22. |
| Resident 1's written cognitive preadmission screening was not dated and contained no diagnoses. |
Report Facts
Census at Inspection: 47
Total Licensed Capacity: 48
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Mandated Correction Date: 5
Staffing Hours: 88
Staffing Hours: 182
Staffing Hours: 137
Inspection Report
Renewal
Census: 44
Capacity: 48
Deficiencies: 29
Mar 21, 2023
Visit Reason
The inspection was a renewal inspection conducted on 03/21/2023 to assess compliance with licensing regulations for Bristol House Memory Care.
Findings
Multiple violations were found related to licensing, staff training, emergency procedures, medical evaluations, sanitary conditions, food safety, and documentation. The facility was issued a first provisional license with required corrections and follow-up inspections.
Deficiencies (29)
| Description |
|---|
| The home's current license was not posted in a conspicuous and public place. |
| The home did not report a resident fall incident to the department within 24 hours. |
| The home did not have the influenza information poster posted year-round. |
| The Department's resident rights poster was not posted in a conspicuous and public place. |
| Staff member hired did not have a criminal background check completed before start date. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person did not receive orientation on fire safety and emergency preparedness topics prior to or during first work day. |
| Staff person did not complete required orientation within 40 scheduled working hours covering resident rights, emergency medical plan, abuse reporting, and incident reporting. |
| Direct care staff person provided unsupervised ADL services without completing Department-approved direct care training and competency test. |
| The home did not have a staff training plan for 2023. |
| Poisonous materials were unlocked and accessible to residents without assessment of residents' ability to safely use or avoid them. |
| Sanitary conditions were not maintained; no paper towels or other sanitary means of hand drying in common bathroom. |
| Trash receptacles in kitchens and bathrooms were uncovered. |
| First aid kit in nurse's station did not include scissors. |
| Exterior building grounds had hazards including broken shutter and PVC fencing on the ground. |
| Food was not protected from contamination; uncovered milk/cream stored in refrigerator. |
| Refrigerator and freezer temperatures were not maintained at required levels; freezer temperature was 10°F and no thermometers present. |
| Outdated or unlabeled food items found in refrigerators and freezers. |
| Written emergency procedures did not include required elements such as emergency medical information confidentiality, emergency contacts, transportation means, staff duties, and alternate means during utility outage. |
| Written emergency procedures were not submitted annually to the local emergency management agency. |
| The home exceeded the maximum safe evacuation time during a fire drill. |
| A fire drill was not conducted during sleeping hours in over a year. |
| Resident medical evaluations were incomplete and not updated annually as required. |
| First aid kit in the home's van was missing required items. |
| Medication storage procedures were not properly implemented; glucometer time was incorrect. |
| Medication administration training records were incomplete or missing documentation. |
| Resident support plan was not signed by the resident who participated in its development. |
| Directions for operating key-locking devices were not conspicuously posted near exit doors. |
| Correction fluid was used on a resident's narcotic control record, making entries illegible and unsigned. |
Report Facts
Census at Inspection: 44
Total Licensed Capacity: 48
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 225
Number of Violations Subject to Fine: 3
Staffing Hours - Total Daily Staff: 88
Staffing Hours - Waking Staff: 66
Residents Served in Secured Dementia Care Unit: 44
Current Hospice Residents: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the letter issuing the first provisional license |
Inspection Report
Renewal
Census: 30
Capacity: 48
Deficiencies: 10
Oct 13, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on October 13, 2021, to review compliance with licensing requirements for Bristol House Memory Care.
Findings
The inspection identified multiple deficiencies including staffing issues with medication administration, equipment repair needs, food protection violations, incomplete medical evaluations, medication administration by unqualified staff, and documentation issues. Plans of correction were accepted and fully implemented by March 2, 2022.
Deficiencies (10)
| Description |
|---|
| No qualified medication administrator scheduled during the 7:00pm-7:00am shift on 10/2/21. |
| Outgoing landline telephone at nurse's station was not operable on 10/13/21. |
| Partially opened uncovered vanilla yogurt present in refrigerator on 10/13/21. |
| Two unlabeled, undated sandwiches discovered in refrigerator. |
| Resident 1 admitted on 2021 was evaluated by a physician but no subsequent evaluation was completed. |
| Resident 1's medical evaluation did not include list of medication prescribed; Resident 2's evaluation lacked medical diagnoses and medication list. |
| Staff person without completed medication administration course administered medications on multiple dates in October 2021. |
| Resident 1, 2, and 3 admitted to Secure Dementia Care Unit had cognitive preadmission screenings completed after admission dates. |
| Resident 3's initial support plan was completed in 2019, not within 72 hours of admission in 2021. |
| Residents 3's and 4's RASP forms were not legible due to faint print. |
Report Facts
License Capacity: 48
Residents Served: 30
Total Daily Staff: 60
Waking Staff: 45
Repeated Violation Date: May 27, 2021
Repeated Violation Date: Oct 20, 2020
Inspection Report
Monitoring
Census: 24
Capacity: 48
Deficiencies: 13
Aug 3, 2021
Visit Reason
The inspection was a monitoring visit conducted on 08/03/2021 to review compliance with state regulations and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to report resident deaths timely, lack of required postings, incomplete staff qualifications and training, sanitary condition issues, and missing documentation in resident records. Plans of correction were accepted or directed with specified completion dates and documentation of implementation.
Deficiencies (13)
| Description |
|---|
| Failure to report resident deaths to the department within 24 hours. |
| Resident's rights poster not posted in a conspicuous and public place. |
| Failure to complete federal background check on an out-of-state staff member. |
| Staff person did not have documentation of high school diploma, GED, or active registry status. |
| No staff certified in first aid on 2nd and 3rd shifts to provide coverage for 24 residents. |
| Staff persons A and B did not receive required fire safety orientation on first day. |
| No staff training plan developed for 2021. |
| Resident #1 was observed urinating in hallway due to locked bedroom and bathroom doors denying access. |
| Bathrooms in resident bedrooms did not have soap at the sink. |
| Emergency procedures not posted in a conspicuous and public place in the home. |
| Weekly menus not posted in a conspicuous place in the facility. |
| Medication prescribed to resident #4 was not available on the medication cart. |
| Resident #5 and #6's records did not include a copy of the reportable incident documenting their death or official death certificate. |
Report Facts
Residents served: 24
License capacity: 48
Staff total daily: 48
Waking staff: 36
Residents without first aid coverage: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed official letters related to inspection and plan of correction |
Inspection Report
Follow-Up
Census: 23
Capacity: 48
Deficiencies: 13
May 27, 2021
Visit Reason
The visit was a follow-up inspection to verify that the submitted plan of correction for previous deficiencies was fully implemented.
Findings
The inspection found multiple deficiencies related to posting of current license, sanitary conditions including shared glucometers, trash receptacle management, medication administration by untrained staff, improper medication storage and labeling, inaccurate medication logs, and failure to follow prescriber's orders. The submitted plan of correction was accepted and deemed fully implemented.
Deficiencies (13)
| Description |
|---|
| The home's current license and current violation report were not posted in a conspicuous and public place. |
| Evidence of shared glucometers was observed with glucose readings for one resident found on another resident's glucometer. |
| A half full, uncovered, unattended trash can was found in the Yellow Finch area kitchen. |
| The outside dumpster lid was open and not in use. |
| Medications were administered by a staff person who had not completed the required medication administration training. |
| A medication pill organizer without instructions or labels was used to administer medications for a resident. |
| Medication blister packages had holes or tape on the foil backing, compromising medication integrity. |
| Pharmacy labels for several residents' medications did not match the medication administration record or narcotic inventory logs. |
| OTC medications and CAM belonging to a resident were not labeled with the resident's name. |
| Glucose readings documented on logs did not match readings on assigned glucometers; glucometer was not calibrated to correct date/time. |
| Shift to shift narcotics counts were not conducted on multiple dates, compromising medication accountability. |
| Medication administration records lacked initials of staff administering medications on certain dates and times. |
| Prescriber's orders were not properly followed, including incorrect insulin dosing and discrepancies in medication inventory and administration. |
Report Facts
Residents served: 23
Total licensed capacity: 48
Staff total daily: 46
Waking staff: 35
Dates medication administered by untrained staff: 6
Dates shift to shift narcotics count not conducted: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Administered medications without completing required medication administration training; no longer employed at facility | |
| Shawn Parker | Signed letter confirming plan of correction fully implemented |
Inspection Report
Enforcement
Census: 27
Deficiencies: 1
May 12, 2021
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to personal care home regulations at Bristol House Memory Care.
Findings
The Department assessed a fine for uncorrected violations under 55 Pa.Code Chapter 2600, specifically a Class III violation under section 185a, resulting in a total fine of $2,160 for the period May 12, 2021 through May 27, 2021.
Severity Breakdown
Class III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Violation of 55 Pa.Code Chapter 2600, Section 185a | Class III |
Report Facts
Fine amount: 2160
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shivani Patel | Enforcement Manager | Contact for appeal and questions regarding the fine |
| Jeanne Parisi | Director | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 48
Deficiencies: 2
Apr 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with direct care staff qualifications and training requirements.
Findings
The facility was found to have deficiencies related to direct care staff qualifications and training. Specifically, one direct care staff person lacked documentation of required qualifications, and another staff person provided unsupervised ADL services without completing and passing the required training and competency test.
Complaint Details
The inspection was complaint-driven as indicated by the reason for the inspection being 'Complaint'.
Deficiencies (2)
| Description |
|---|
| The home could not provide documentation or verify that direct care staff person A has a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person A began providing unsupervised ADL services without completing and passing the Department-approved direct care training course or competency test. |
Report Facts
Residents Served: 21
License Capacity: 48
Total Daily Staff: 42
Waking Staff: 32
Inspection Report
Renewal
Census: 27
Capacity: 48
Deficiencies: 33
Oct 20, 2020
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 deficiencies including issues with record confidentiality, contract signatures, privacy during medication administration, criminal background checks, staff orientation, locking of poisonous materials, sanitary conditions, furniture and equipment maintenance, medication storage and administration, resident support plans, and safety concerns related to egress and key-locking devices. Several violations were repeated from prior inspections.
Deficiencies (33)
| Description |
|---|
| Licensing Inspection Summary was posted in a locked cabinet, not easily accessible to residents and visitors. |
| Resident records were not kept confidential; electronic records were visible to residents and staff. |
| 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. |
| Staff A administered medication to Resident #2 in a dining room with other residents present, compromising privacy. |
| No criminal background checks for Staff B and Staff C. |
| Staff persons A and B did not receive required fire safety orientation topics on their first day. |
| Staff persons A and B did not receive required orientation on resident rights and abuse reporting within 40 hours. |
| Ancillary staff person C did not have a general orientation to specific job functions. |
| Unattended housekeeping cart with poisonous materials was unlocked and accessible to residents. |
| Staff A was not wearing gloves when administering medications. |
| Men's bathroom door was locked and out of order; laundry room washing machine was out of order. |
| First aid kit in Blue Jay section lacked antiseptic, thermometer, scissors, breathing shield, and eye coverings. |
| Resident #3 was denied access to bedroom due to locked door. |
| Bedside table and lamp in Resident #3's room were approximately 4 feet away from bed and lamp was not operable at bedside. |
| Refrigerator temperature in Blue Jay section was 50°F, exceeding required 40°F. |
| Lint accumulated in lint trap of Blue Jay laundry room dryer. |
| Emergency food supply was insufficient to serve 27 residents for three days and was not stored or designated for emergencies. |
| Blocked egress near room 315 due to chair blocking access to emergency door release button. |
| Menu stating specific food served was not posted in a conspicuous place. |
| Glucometers for Residents #4 and #5 were not calibrated to correct date/time; blood sugar readings were inaccurately recorded; missing narcotics could not be accounted for. |
| Refusal of medication by Resident #4 was not documented as reported to prescriber. |
| Resident #6 was observed using an unprescribed geri chair after a fall; blood sugar checks for Resident #2 were not performed as prescribed. |
| Resident Assessment and Support Plans (RASPs) for Residents #1, #3, #6, and #7 were not signed by residents or responsible parties without documentation of refusal or inability to sign. |
| Resident #1 lacked documentation of consent to live in secured dementia care unit. |
| Code to locked gate outside Gold Finch section was missing or incorrect. |
| Resident #7 entered unoccupied Gold Finch section unsupervised, contrary to support plan requiring supervision. |
| Entry on Resident #4's narcotic count sheet was overwritten without staff initials. |
| Resident photos for Residents #1, #3, and #6 were not dated, making age of photos indeterminable. |
| First aid kit did not include thermometer, gauze pads, or eye coverings. |
| First aid kit was located in locked room inaccessible to all staff. |
| Freezer temperature in Blue Jay section was 10°F, exceeding required 0°F. |
| Directions for operating key-locking devices were not conspicuously posted near doors on Blue Jay or Gold Finch. |
Report Facts
License Capacity: 48
Residents Served: 27
Staffing Hours: 41
Waking Staff: 31
Fine Amount: 225
Fine Days: 15
Residents Served: 18
Staffing Hours: 27
Waking Staff: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Benoit | Administrator | Named as facility administrator |
| Arvind Bhakta | Manager | Named as facility manager |
| Jamie Buchenauer | Deputy Secretary | Signed enforcement and licensing letters |
| Susan Smith | Lead Inspector | Lead inspector for 10/20/2020 inspection |
| Claire Mendez | Lead Reviewer | Lead reviewer for follow-up and POC submissions |
| Sabrina Freeman | Lead Inspector | Lead inspector for 01/15/2021 inspection |
| Shawn Parker | Lead Reviewer | Lead reviewer for document submissions and exceptions |
| Shivani Patel | Enforcement Manager | Named in enforcement appeal instructions |
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