Inspection Report
Complaint Investigation
Census: 40
Capacity: 60
Deficiencies: 3
Mar 3, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation related to a resident's elopement from the secured dementia care unit.
Findings
The investigation found that a resident eloped from the memory care unit and was found outside the building in cold temperatures. The facility lacked a specific policy for monitoring residents requiring extensive supervision beyond redirection and engagement. Additional assessments and timely support plans were not completed as required. The facility submitted plans of correction which were accepted and later fully implemented.
Complaint Details
The visit was complaint-related due to an incident where a resident eloped from the secured dementia care unit. The complaint was substantiated as deficiencies were found in supervision, assessment, and support planning.
Deficiencies (3)
| Description |
|---|
| Failure to prevent resident elopement and lack of specific monitoring policy for residents requiring extensive supervision. |
| Failure to conduct additional assessments following significant incidents such as elopement. |
| Failure to develop, implement, and document a support plan within 72 hours of admission to the secured dementia care unit. |
Report Facts
Residents served: 40
License capacity: 60
Residents in secured dementia care unit: 13
Staff on unit: 7
Temperature range: -14
Temperature range: -25
Temperature at elopement time: 30
Time to locate resident: 20
Inspection Report
Monitoring
Census: 41
Capacity: 60
Deficiencies: 4
Feb 20, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified several deficiencies including unlocked and unattended resident hourly checks accessible to unauthorized persons, improper covers on bedside mobility devices, medication cards with punctured blister foil exposing medication, and unlabeled OTC medication bottles. The facility submitted and implemented plans of correction for all deficiencies.
Deficiencies (4)
| Description |
|---|
| Resident hourly checks were unlocked, unattended and accessible to all residents, staff and visitors on the reception desk in the Wellspring Unit. |
| The bedside mobility device in resident room did not have a proper cover, leaving an opening approximately 10 inches wide by 20 inches high uncovered. |
| Medication cards were observed to have punctured blister foil with medication still present in the spot exposing it to contamination or improper sanitation. |
| A bottle of OTC medication was found in the Cottonwood medication cart that was not labeled with any resident’s name or room number. |
Report Facts
Residents Served: 41
License Capacity: 60
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 27
Residents Age 60 or Older: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Named in medication storage and labeling deficiencies and corrective actions | |
| Administrator/designee | Responsible for education and auditing related to resident record confidentiality and accommodation deficiencies |
Inspection Report
Renewal
Census: 43
Capacity: 60
Deficiencies: 20
Dec 16, 2024
Visit Reason
The inspection was conducted as a renewal, provisional license inspection to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple deficiencies including issues with fire drills, dietary needs, medication storage and administration, resident record confidentiality, and physical accommodations. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (20)
| Description |
|---|
| Residents did not evacuate to a designated meeting place during fire drills. |
| Resident's special dietary needs were not followed, resulting in a choking incident. |
| Medication storage procedures were not properly followed, including failure to document medication sign-out times. |
| Medications were not administered as prescribed by the prescriber. |
| Resident assessments were incomplete, missing evaluations for memory and safety needs. |
| Resident records lacked documentation of dietary restrictions prior to a choking incident. |
| Resident records were left unlocked and accessible to unauthorized persons. |
| Carbon monoxide alarm was improperly located too close to the boiler. |
| Resident contract was not signed by the resident. |
| Resident record lacked signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff lacked required high school diploma, GED, or active registry status. |
| Physical site accommodations such as bedside mobility device covers were inadequate. |
| Trash receptacles in kitchens and bathrooms were uncovered. |
| Trash outside the home was uncovered and improperly stored. |
| Leftover food was unlabeled and undated in kitchenettes. |
| Fire drills were sometimes announced and documentation was incomplete or inaccurate. |
| Fire alarms were not activated during some fire drills. |
| Loose pills were found in medication carts. |
| Resident was not educated on the right to refuse medication. |
| No objection statement was missing for resident admission to secured dementia care unit. |
Report Facts
License Capacity: 60
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 15
Total Daily Staff: 69
Waking Staff: 52
Residents Served: 41
Residents Served in Secured Dementia Care Unit: 13
Total Daily Staff: 68
Waking Staff: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letters and notices. |
Inspection Report
Follow-Up
Census: 41
Capacity: 60
Deficiencies: 6
Sep 30, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit for incident and monitoring purposes on 09/30/2024 and 10/10/2024, with follow-up reviews and plan of correction submissions through 04/11/2025.
Findings
The facility was found deficient in several areas including failure to evacuate residents to designated meeting places during fire drills, failure to meet residents' special dietary needs resulting in a choking incident, improper medication storage and documentation, failure to follow prescriber's orders for medication administration, incomplete resident assessments, and incomplete dietary restriction documentation. Plans of correction were accepted and implemented by 04/02/2025.
Deficiencies (6)
| Description |
|---|
| Residents did not evacuate to a designated meeting place away from the building or within the fire-safe area during fire drills. |
| Resident's special dietary needs were not followed, resulting in a choking incident on a piece of chicken inconsistent with the prescribed mechanical soft diet. |
| Failure to properly document the time morphine medication was signed out and missing blood glucose readings in resident logs. |
| Failure to administer prescribed medication at the correct time and failure to perform required blood glucose checks. |
| Resident annual assessment was incomplete, missing evaluation of short term memory, long term memory, and ability to safely use or avoid poisonous materials. |
| Resident record did not include dietary restrictions prior to a choking incident and lacked diet communication forms. |
Report Facts
License Capacity: 60
Residents Served: 41
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 11
Resident with Mobility Need: 27
Residents Age 60 or Older: 41
Total Daily Staff: 68
Waking Staff: 51
Inspection Report
Renewal
Census: 44
Capacity: 60
Deficiencies: 16
Jan 8, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of Juniper Village at Bucks County Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to post required regulations, lack of staff training on protective services, unsecured poisonous materials accessible to residents, sanitary deficiencies, missing emergency telephone numbers, improper refrigerator/freezer temperatures, insufficient emergency food and water supplies, incomplete fire drill records, medication administration errors, and incomplete support plan signatures. Plans of correction were directed with proposed completion dates mostly in early 2024.
Deficiencies (16)
| Description |
|---|
| A copy of the chapter 2600 regulations was not posted in a conspicuous and public place in the home. |
| Staff person A did not receive training in The Older Adult Protective Services Act during training year 2023. |
| A bottle of hand sanitizer was unlocked, unattended, and accessible to residents in the secure dementia care unit. |
| No paper towels, mechanical hand dryer or other sanitary means of hand drying in the common shower room on the second floor. |
| No emergency telephone numbers posted on or by the telephone in room 217. |
| Temperature in the main-kitchen freezer was 7 degrees Fahrenheit, above the required 0°F or below. |
| The home did not maintain at least a 3-day supply of nonperishable food and drinking water for residents. |
| The home's emergency procedures and smoke detector policy did not indicate procedures when smoke detectors or fire alarms are inoperable. |
| The home did not provide records of unannounced fire drills for several months in 2023. |
| The home’s fire drill records for 2023 did not include number of residents evacuated, times of drills, or routes taken. |
| Fire drills were not held during sleeping hours as required every 6 months. |
| The home's posted menu only covered six days in advance instead of one week. |
| Staff person B left a cart containing residents' medications unlocked and unattended. |
| The home's glucometer log for resident #3 showed inconsistent blood sugar readings. |
| Resident #2 missed doses of prescribed medication without documentation. |
| The assessor of Resident #4's support plan did not sign and date the plan. |
Report Facts
License Capacity: 60
Residents Served: 44
Residents Served in Secure Dementia Care Unit: 16
Staffing Hours - Resident Support Staff: 60
Total Daily Staff: 138
Waking Staff: 104
Fine Per Resident Per Day: 5
Calculated Fine: 200
Census at Inspection: 40
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Renewal
Census: 44
Capacity: 60
Deficiencies: 15
Jan 8, 2024
Visit Reason
The inspection was a renewal licensing inspection conducted on January 8, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to post required regulations, incomplete staff training, unsecured poisonous materials, sanitary deficiencies, missing emergency telephone numbers, improper refrigerator/freezer temperatures, insufficient emergency food/water supply, inoperable smoke detector procedures, incomplete fire drill records, medication storage and administration issues, and incomplete support plan signatures.
Deficiencies (15)
| Description |
|---|
| A copy of the chapter 2600 regulations was not posted in a conspicuous and public place in the home. |
| Staff person A did not receive training in The Older Adult Protective Services Act during training year 2023. |
| A bottle of hand sanitizer was unlocked, unattended, and accessible to residents in the secure dementia care unit. |
| No paper towels, mechanical hand dryer or other sanitary means of hand drying in the common shower room on the second floor. |
| No emergency telephone numbers posted on or by the telephone in room 217. |
| Main-kitchen freezer temperature was 7 degrees Fahrenheit, above the required 0°F. |
| The home had only 90 gallons of emergency drinking water, less than the required 132 gallons for 44 residents. |
| Emergency procedures and smoke detector policy did not indicate procedures when smoke detector or fire alarm is inoperable. |
| Fire drills were not held monthly during several months of 2023 and records were incomplete. |
| Emergency telephone numbers were missing on or by the telephone in room 217. |
| Posted menu only covered six days in advance instead of one week. |
| Medication cart was left unlocked and unattended during medication retrieval. |
| Glucometer log showed inconsistent blood sugar readings for resident #3. |
| Resident #2 missed doses of Synthroid without documentation on medication administration record. |
| Assessor of Resident #4's support plan did not sign and date the plan. |
Report Facts
Fine amount: 200
Census at inspection: 44
Total licensed capacity: 60
Secure Dementia Care Unit capacity: 21
Residents served in secure dementia care unit: 16
Staffing hours: 60
Total daily staff: 138
Waking staff: 104
Fine per resident per day: 5
Fine calculated per day: 200
Emergency drinking water required: 132
Emergency drinking water available: 90
Fire drill missing months: 5
Residents evacuated during fire drill: 24
Residents present during fire drill: 28
Medication discrepancy Alprazolam: 2
Medication discrepancy Methylphenidate: 2
Inspection Report
Complaint Investigation
Census: 43
Capacity: 60
Deficiencies: 10
Oct 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Juniper Village at Bucks County Senior Living.
Findings
Multiple deficiencies were identified including missing criminal background check for a staff member, administrator qualifications not met, insufficient administrator staffing hours, lack of required administrator training, unlocked poisonous materials accessible to residents, broken scale for weighing residents, incomplete resident support plan documentation, missing directions for key locking devices, and incomplete resident face sheet information.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason stated as 'Complaint'.
Deficiencies (10)
| Description |
|---|
| A criminal background check could not be provided for staff member A. |
| Administrator did not have required qualifications such as a nursing license or associate degree. |
| Administrator was not present in the home for an average of 20 hours per week as required. |
| Staff member A did not provide documentation of completion of the 100-hour standardized Department-approved administrator training course. |
| Staff member A did not provide documentation of 24 hours of annual training; last training was from May 2022. |
| Two bottles of McKesson Premium Hand Sanitizer were unlocked and accessible to residents in the secured dementia care unit. |
| The scale used to weigh residents in personal care and memory care units was broken since July 2023. |
| Resident support plan did not clearly document how laundry service needs would be met for Resident 1. |
| No directions were posted near the main entrance to the memory care unit for key locking devices. |
| Resident 1's face sheet was missing eye and hair color information. |
Report Facts
License Capacity: 60
Residents Served: 43
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 4
Resident Mobility Need: 23
Residents Age 60 or Older: 43
Total Daily Staff: 66
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in multiple findings including missing criminal background check, lack of administrator qualifications, insufficient staffing hours, and missing training documentation. | |
| Assistant Executive Director | Performed in-service trainings and was assigned as designee in absence of administrator. | |
| Director of Wellness | Updated resident support plan and printed face sheets to correct documentation deficiencies. | |
| Executive Director | Conducted in-service training with the administrator regarding staffing hours. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 60
Deficiencies: 7
Apr 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/20/2023 and 04/21/2023.
Findings
The inspection found multiple deficiencies including missing resident-home contracts and signatures, lack of signed statements acknowledging receipt of resident rights, sanitation issues in the kitchen, evidence of bedbug and mice infestation, failure to educate residents on the right to refuse medication, and incomplete documentation in a resident's support plan.
Complaint Details
The inspection was triggered by a complaint as stated under Inspection Information on page 2.
Deficiencies (7)
| Description |
|---|
| Residents #1 and #2 did not have a resident-home contract. |
| Resident-home contract for resident #3 was not signed by the resident. |
| Records for residents #1, #2, and #3 lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Sanitation issues found in the kitchen including floor drains, floor under cook/steamline, and trash cans needing cleaning. |
| Bedbugs found in room 206 and mice found in the kitchen. |
| Residents #1, #2, and #3 were not educated on the right to refuse medication if they believed there was a medication error. |
| Resident #3's support plan did not document the need for an enabler bar. |
Report Facts
License Capacity: 60
Residents Served: 40
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 4
Residents Age 60 or Older: 40
Residents with Mental Illness: 1
Residents with Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 44
Capacity: 60
Deficiencies: 12
Mar 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Juniper Village at Bucks County Senior Living.
Findings
Multiple deficiencies were found including staff qualifications, orientation and training deficiencies, hazardous conditions with resident equipment, sanitary issues, malfunctioning equipment, incomplete resident assessments, and failure to provide dietary alternatives. Plans of correction were accepted and implemented by June 15, 2023.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason stated as 'Complaint'.
Deficiencies (12)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person B did not receive orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff person B did not complete training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect within 40 scheduled working hours. |
| Direct care staff persons A and B provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Resident 4's bed had an uncovered enabler bar creating a hazardous condition. |
| Resident #1's room had a strong smell of feces and soiled clothing on the floor not cleaned up. |
| P-tac heating units in resident 2's room and activity room were not working. |
| Resident 3's dental care needs were not addressed with follow-up appointments despite prior recommendations. |
| Dietary alternative was not provided for resident 3 requiring IDDSI-Soft & Bite sized diet. |
| Resident 4’s most recent assessment was incomplete and did not include need for enabler bar on bed. |
| Resident 1’s medical evaluation was not completed within 60 days prior to admission to the Secure Dementia Care Unit. |
| Resident 3's record did not include a photograph no more than 2 years old. |
Report Facts
Residents Served: 44
License Capacity: 60
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 3
Residents Age 60 or Older: 44
Residents with Mobility Need: 19
Residents with Physical Disability: 3
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 44
Capacity: 60
Deficiencies: 25
Sep 15, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and to verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including delayed provision of staff lists, expired boiler certificate, missing resident contracts and signatures, inadequate staff training and orientation, fire safety issues, medication storage and administration problems, and incomplete preadmission screening documentation. The submitted plan of correction was accepted and fully implemented by the follow-up date.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit including 'Complaint'. The report does not explicitly state substantiation status.
Deficiencies (25)
| Description |
|---|
| Delayed provision of the home's staff list to the Department's agent. |
| Expired boiler certificate since 1/18/21. |
| Failure to post waiver request and Department’s written decision in a conspicuous place. |
| Resident #1 did not have a resident-home contract. |
| Resident #2's resident-home contract was not signed by the resident. |
| Resident #2's contract did not include a signed statement about rent rebate information. |
| Residents #1, #2, and #3 did not have signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff persons B and C lacked required high school diploma, GED, or active nurse aide registry status. |
| Staff person A (administrator) had not completed Department-approved orientation program. |
| Staff persons B and C did not receive required fire safety orientation on first day. |
| Staff persons B, C, and D did not complete required Resident Rights and Abuse training within 40 hours. |
| Staff persons B and C provided unsupervised ADL services without completing required direct care training and competency test. |
| No bedside table or shelf beside resident #4's bed. |
| Resident #4 did not have access to an operable lamp or lighting at bedside. |
| Lack of documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Kitchen fire extinguisher in Memory Care kitchen was overcharged. |
| Fire drill record dated incorrectly for drill conducted on 6/30/22. |
| Only one exit route used during fire drills from December 2021 to August 2022. |
| One week advanced menu was not posted as required. |
| Resident #1's glucometer was not calibrated to correct date and time. |
| Medication prescribed as needed for Resident #2 was not available in the home. |
| Residents #1, #2, and #3 were not educated on their right to refuse medication if they believed there was a medication error. |
| Resident #2 and #5 had preadmission screening forms completed after admission dates. |
| Resident #3's support plan was not signed by the assessor. |
| Resident #2 and #5 had written cognitive preadmission screening completed after admission to secured dementia care unit. |
Report Facts
Residents Served: 44
License Capacity: 60
Staffing Hours: 81
Waking Staff: 61
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Administrator | Named in findings related to delayed staff list provision and incomplete orientation |
| Staff person B | Named in findings related to lack of qualifications, incomplete fire safety orientation, incomplete rights/abuse training, and direct care training | |
| Staff person C | Named in findings related to lack of qualifications, incomplete fire safety orientation, incomplete rights/abuse training, and direct care training | |
| Staff person D | Named in findings related to incomplete rights/abuse training |
Inspection Report
Renewal
Census: 42
Capacity: 60
Deficiencies: 15
Jun 29, 2021
Visit Reason
The inspection was a renewal inspection conducted on 06/29/2021 and 06/30/2021 at Juniper Village at Bucks County Senior Living to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unsecured resident medical records, unsigned resident contracts, incomplete quality management plan, delayed refund of resident payments after death, missing signed resident statements, privacy violations related to camera placement and medication administration, inadequate staff orientation and training, medication administration record errors, failure to follow prescriber's orders, and unsecured dementia care unit exit gate. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (15)
| Description |
|---|
| Resident medical records were unlocked, unattended, and accessible in the dining room closet on the second floor. |
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Quality management plan did not address reportable incident and condition reporting procedures, complaint procedures, staff training, licensing violations, plans of correction, or resident/family councils. |
| Delayed refund of previously paid charges to the estate of a deceased resident beyond the required timeframe. |
| Resident records did not contain signed statements acknowledging receipt of resident rights and complaint procedures for residents #1 and #2. |
| Cameras in personal care hallways and memory care unit were positioned pointing towards resident rooms, violating privacy. |
| Medication was administered to Resident #4 in the dining room in view of others instead of a private location. |
| Staff persons A, B, and C did not receive required fire safety and emergency preparedness orientation prior to or during their first work day. |
| Staff persons A, B, and C did not complete emergency medical plan training within 40 scheduled working hours. |
| Direct care staff person B provided unsupervised ADL services without completing required direct care training and competency test. |
| Staff training plan did not include required training courses for each staff person; annual fire safety training was conducted online rather than by a fire safety expert. |
| Medication administration record for Resident #2 lacked initials of staff who administered medications on 06/24/21 at 9am. |
| Resident #1's glucose level was above 400 on 06/20/21 at 12:00 pm; the home did not contact the physician as ordered. |
| Resident #4 was observed receiving morning medications at 10:30am instead of prescribed 9am time. |
| The outside gate in the dementia unit courtyard was not locked with an electronic or magnetic locking system, allowing easy exit to a parking lot. |
Report Facts
License Capacity: 60
Residents Served: 42
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 2
Total Daily Staff: 67
Waking Staff: 50
Residents with Mobility Need: 25
Inspection Report
Renewal
Capacity: 60
Deficiencies: 0
Jan 5, 2021
Visit Reason
The document is a renewal application and license issuance for Juniper Village at Bucks County Senior Living to operate as a Personal Care Home, with the Department advising that an annual inspection will be conducted within the next twelve months.
Findings
The Department issued a regular license in response to the renewal application and stated that if evidence of noncompliance is found during the upcoming inspection, enforcement action will be taken.
Report Facts
Maximum capacity: 60
Secure Dementia Care Unit capacity: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
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