Inspection Reports for
Juniper Village at Brookline – Wellspring Memory Care

The inspection was complaint-related, triggered by allegations of abuse and medication administration issues. The report details substantiated findings of abuse, medication errors, and inadequate behavioral interventions.

The investigation found multiple deficiencies related to abuse, medication record keeping, following prescriber's orders, medication error reporting and documentation, positive interventions, and resident assessments. The facility submitted plans of correction addressing these issues, including staff education, monitoring, and environmental safety improvements.

The inspection was complaint-related as indicated by the reason 'Complaint' in the inspection information. No deficiencies or citations were found, implying the complaint was not substantiated.

No regulatory citations or deficiencies were identified as a result of the inspection.

The inspection identified multiple deficiencies including lack of carbon monoxide detectors near fossil fuel devices, improper refund for a deceased resident, unverified educational qualifications of direct care staff, unlocked poisonous materials accessible to residents, lack of operable bedside lighting, improperly labeled leftover food, medication record discrepancies, failure to follow prescriber's orders, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by 08/26/2024.

The inspection was complaint-related; however, no deficiencies were found and no substantiation status was stated.

No regulatory citations or deficiencies were identified as a result of this inspection.

The inspection found deficiencies related to annual training topics for direct care staff, medication administration certification documentation, and labeling of over-the-counter medications. The submitted plan of correction was fully implemented and compliance was maintained.

The visit was complaint-related, investigating an incident involving Resident #1's unwitnessed fall and delayed medical care. The complaint was substantiated with findings of delayed reporting and medical intervention.

The facility was found to have initially refused access to certain internal investigation records but later provided required resident records. Resident #1 experienced an unwitnessed fall that was not reported timely by staff, and medical care was delayed until a mobile x-ray was performed, resulting in a diagnosis of a left hip fracture. The facility disputed some citations but implemented corrective actions including education and monitoring.

No regulatory citations were identified as a result of this inspection.

No regulatory citations were identified as a result of this inspection.

The Department has issued a regular license in response to the renewal application. The document states that if noncompliance is found during the upcoming inspection, enforcement action will be taken.

The facility was found to have fully implemented the submitted plan of correction. Two specific deficiencies were noted and corrected: one related to missing physician license number on a resident's medical evaluation and another related to the format and posting of weekly menus.

No regulatory citations were identified as a result of this inspection.

The inspection was complaint-driven and partial in scope. The medication error was substantiated and corrective actions were verified as implemented.

A medication error was identified where resident #1 received an incorrect dose of medication on multiple dates in July 2019. The facility implemented corrective actions including staff education and monitoring, and the plan of correction was found fully implemented during the February 5, 2020 review.

No inspection findings are reported in this document. It serves as a license renewal notification and certificate of compliance for the facility.

Violations of 55 Pa. Code Ch. 2600 were found during the annual renewal inspection. The facility submitted plans of correction addressing issues related to resident privacy, staff licensing and training, medical evaluations for secured dementia care, and hospice resident documentation.

No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of the facility's authorized capacity.

The certificate confirms the licensed capacity of 38 residents for the facility and states that the expiration date remains unchanged despite the certificate number update.