Inspection Reports for Revelle of Bucks County
945 York Rd, Warminster, PA 18974, United States, PA, 18974
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Inspection Report
Follow-Up
Census: 37
Capacity: 100
Deficiencies: 5
Feb 20, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to personal hygiene assistance, contract signatures, dignity and respect in resident care, record of staff training, and significant change assessments were addressed with corrective actions including staff termination, education, monitoring, and documentation.
Complaint Details
The visit was complaint-related, triggered by an incident involving resident care and dignity violations. Staff Person A was suspended and terminated following the incident. The complaint was substantiated as corrective actions were implemented.
Deficiencies (5)
| Description |
|---|
| Resident did not receive required assistance with personal hygiene as indicated in their assessment and support plan. |
| Resident-residence contract was not signed by the resident. |
| Staff Person A violated resident's right to dignity and respect by failing to provide required stand-by assistance and leaving resident alone in the bathroom while verbally escalating the situation. |
| Residence's record of direct care staff training did not include Staff Person A's training history with required details. |
| No additional written assessment was completed for a resident after a significant change incident involving injury to spouse. |
Report Facts
Residents Served: 37
License Capacity: 100
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 10
Current Hospice Residents: 2
Residents Age 60 or Older: 37
Residents with Mobility Need: 19
Total Daily Staff: 56
Waking Staff: 42
Inspection Report
Renewal
Census: 36
Capacity: 100
Deficiencies: 8
Jan 15, 2025
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of the assisted living facility to determine compliance with 55 Pa. Code Chapter 2800.
Findings
The facility was found to be in compliance overall, but several deficiencies were identified including issues with resident equipment repair, sanitary conditions, food storage, clothing laundering, annual medical evaluations, medication storage procedures, support plan revisions, and staff training. All deficiencies had plans of correction accepted and were implemented by April 7, 2025.
Deficiencies (8)
| Description |
|---|
| Bedside mobility device was not securely attached to Resident #1's bed, creating entrapment hazards. |
| Dried feces found on the toilet seat of Resident #1's bathroom. |
| Opened and unsealed food items (cookie dough and fried steak) found in the walk-in freezer. |
| Resident laundry hampers were unlabeled, risking loss or misplacement of clothing. |
| Resident #2's most recent annual medical evaluation was completed late. |
| Medication administration record (MAR) documentation errors for Resident #3's blood sugar readings. |
| Resident #1's support plan did not include the use of a bedside mobility device observed in use. |
| Direct Care Staff Person B in the special care unit had only 3 hours of dementia care training instead of the required 8 hours during the 2024 training year. |
Report Facts
License Capacity: 100
Residents Served: 36
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 11
Hospice Residents: 3
Staff Total Daily: 58
Waking Staff: 44
Residents with Mobility Need: 22
Residents 60 Years or Older: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Staff Person A | Medication Technician | Named in medication administration record documentation errors. |
| Direct Care Staff Person B | Direct Care Staff | Named in deficiency for insufficient dementia care training. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 100
Deficiencies: 3
Dec 30, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 12/30/2024 and 02/25/2025.
Findings
The facility was found deficient in completing initial medical evaluations within required timeframes, following prescriber's medication orders accurately, and maintaining a system to identify and document medication errors. The submitted plan of correction was fully implemented as of 04/07/2025.
Complaint Details
The inspection was triggered by a complaint and incident. The report notes repeated medication administration errors and lack of documentation system for medication errors. The complaint was substantiated by findings.
Deficiencies (3)
| Description |
|---|
| Failure to provide initial medical evaluation within required timeframe for resident admission. |
| Medication administration did not follow prescriber's orders, resulting in missed doses and incorrect dosing over at least 2.5 months. |
| Lack of a system to identify and document medication errors and patterns of errors. |
Report Facts
Residents Served: 38
License Capacity: 100
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 11
Residents Age 60 or Older: 38
Residents with Mobility Need: 22
Staffing Hours - Total Daily Staff: 60
Staffing Hours - Waking Staff: 45
Inspection Report
Monitoring
Census: 40
Capacity: 100
Deficiencies: 1
Dec 2, 2024
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review compliance with regulations and verify the implementation of a previously submitted plan of correction.
Findings
The inspection found one deficiency related to outdated or improperly stored food, specifically an unlabeled and undated container of turkey in the kitchen refrigerator. The facility promptly corrected the issue and implemented ongoing monitoring and education to ensure compliance.
Deficiencies (1)
| Description |
|---|
| There was an unlabeled, undated container of turkey in the refrigerator in the kitchen. |
Report Facts
License Capacity: 100
Residents Served: 40
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 10
Current Hospice Residents: 3
Residents Age 60 or Older: 40
Residents with Mobility Need: 22
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 9
Sep 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation with multiple onsite and offsite review dates from 09/26/2024 to 10/18/2024.
Findings
The inspection identified several deficiencies including failure to provide immediate access to records and staff communication, incomplete staff orientation and training on fire safety, resident rights, abuse reporting, direct care training, and dementia care. Additional deficiencies included untimely documentation of resident preadmission screening and support plans, and failure to post current menus.
Complaint Details
The visit was complaint-related as indicated by the inspection reason and included multiple follow-up submissions and reviews to verify correction of deficiencies.
Deficiencies (9)
| Description |
|---|
| Failure of staff person A to respond to department agent's request for clarification and communication. |
| Staff person B did not receive required orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff person B did not complete required orientation training on resident rights, emergency medical plan, abuse reporting, and core competencies within 40 scheduled working hours. |
| Direct care staff person C provided unsupervised assisted living services without completing department-approved direct care training and competency test. |
| Menus posted were for June, July, and August, not for September. |
| Resident's written cognitive preadmission screening was not dated, making timely completion impossible to verify. |
| Resident's initial support plan was completed late due to failure to lock assessment appropriately. |
| Resident's support plan was not updated to address behavior of blocking room door with furniture. |
| Direct care staff person B did not complete required dementia care training within first 30 days of hire. |
Report Facts
License Capacity: 100
Residents Served: 47
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 12
Total Daily Staff: 72
Waking Staff: 54
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 6
May 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/09/2024 to review compliance and follow up on submitted plans of correction.
Findings
The inspection found multiple deficiencies including incomplete medical evaluations lacking immunization and tuberculosis testing, improper use of chemical restraints, lack of appropriate activities for residents in the secured dementia care unit, unsigned resident support plans, incomplete preadmission cognitive screenings, and failure to update support plans to reflect changes in resident condition. Plans of correction were accepted and evidence of completion was implemented by 07/08/2024.
Complaint Details
The inspection was complaint-driven and included a follow-up on the plan of correction submission. The complaint involved issues such as medical evaluation omissions, improper chemical restraint use, inadequate activity programming, and deficiencies in resident support plans and screenings.
Deficiencies (6)
| Description |
|---|
| Medical evaluation for a resident did not include immunizations and tuberculosis testing. |
| Use of chemical restraint medication for agitation/anxiety was administered improperly. |
| The residence lacked a program of activities designed to promote active participation for residents in the Secured Dementia Care Unit. |
| Resident assessment/support plan was not signed by the assessor, resident, or family/designee. |
| Written cognitive preadmission screening was missing determination that the resident's needs can be met by the residence. |
| Support plan for a resident was not updated to reflect changes in condition including transfer needs and hospice care. |
Report Facts
License Capacity: 100
Residents Served: 47
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 14
Resident Mobility Need: 19
Total Daily Staff: 66
Waking Staff: 50
Inspection Report
Complaint Investigation
Census: 52
Capacity: 100
Deficiencies: 4
Dec 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 12/27/2023 to review compliance and follow-up on a plan of correction submission.
Findings
The inspection found multiple deficiencies including inadequate staffing leading to missed medication administration for seven residents, failure to follow prescriber’s orders, and incomplete support plan documentation with missing signatures from assessors and residents. The submitted plan of correction was determined to be fully implemented by the follow-up date.
Complaint Details
The inspection was complaint-driven and included a follow-up on the plan of correction submission. The complaint was substantiated based on findings of missed medication administration and documentation deficiencies.
Deficiencies (4)
| Description |
|---|
| Staffing was insufficient during the overnight shift causing seven residents to miss their medication. |
| Seven residents did not receive prescribed medication as ordered by the prescriber. |
| Resident initial assessment and support plan was not signed by the assessor and the resident. |
| Resident initial assessment support plan was not signed by the resident and no notation of refusal or inability to sign was documented. |
Report Facts
Residents served: 52
License capacity: 100
Residents missed medication: 7
Staffing hours: 84
Waking staff hours: 63
Inspection Report
Follow-Up
Census: 66
Capacity: 100
Deficiencies: 1
Sep 19, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident, with a focus on reviewing the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with measures including installation of locking drawers to safeguard resident property and staff re-education on resident rights and abuse prevention.
Complaint Details
The visit was complaint-related, involving an incident where a resident's cash was missing from their dresser drawer. The resident had not left the facility prior to discovering the missing money. The complaint was addressed with a plan of correction.
Deficiencies (1)
| Description |
|---|
| A resident discovered cash missing from their dresser drawer, indicating a violation of abuse/neglect regulations. |
Report Facts
License Capacity: 100
Residents Served: 66
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 12
Residents Age 60 or Older: 66
Residents with Mobility Need: 12
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 4
Jun 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation to address specific concerns at the facility.
Findings
The inspection identified multiple deficiencies including failure of staff to maintain sanitary conditions, incomplete preliminary support plan signatures, missing dates on significant change assessments, and incomplete resident records such as missing recent photographs.
Complaint Details
The visit was complaint-related as explicitly stated, with the reason for inspection noted as 'Complaint'.
Deficiencies (4)
| Description |
|---|
| Staff member failed to wash hands before administering eye drops and checking blood sugar of residents. |
| Resident #3 and designated person did not sign and date the preliminary support plan. |
| Resident #3's significant change assessment plan did not include the date of completion. |
| Resident #3's record does not include a photograph of the resident that is no more than 2 years old. |
Report Facts
License Capacity: 100
Residents Served: 47
Memory Care Unit Capacity: 24
Memory Care Residents Served: 13
Hospice Residents: 5
Total Daily Staff: 60
Waking Staff: 45
Residents with Mobility Need: 13
Residents 60 Years or Older: 47
Inspection Report
Complaint Investigation
Census: 46
Capacity: 100
Deficiencies: 2
May 24, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility on 05/24/2023.
Findings
The inspection found two deficiencies related to abuse/neglect and prohibited procedures. One resident was punched by another causing injury, and a staff member improperly used a washcloth to prevent a resident from leaving their room. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related and incident-based. The complaint was substantiated by findings of abuse/neglect and prohibited procedures.
Deficiencies (2)
| Description |
|---|
| Resident #1 punched Resident #2 in the face causing injury requiring emergency room treatment. |
| Staff placed a washcloth between resident #1's door and door frame to prevent the resident from leaving the room, constituting prohibited seclusion. |
Report Facts
Residents served: 46
License capacity: 100
Special care unit capacity: 30
Special care unit residents served: 13
Residents age 60 or older: 45
Residents with mobility need: 19
Inspection Report
Monitoring
Census: 48
Capacity: 100
Deficiencies: 1
Apr 24, 2023
Visit Reason
The visit was a monitoring inspection conducted on 04/24/2023 to review the facility's compliance status and plan of correction implementation.
Findings
The submitted plan of correction was determined to be fully implemented. One deficiency was noted regarding medication storage where a medication on the cart was past the discard date according to manufacturer instructions. The facility implemented daily and weekly audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Medication on the cart was present with an open date past the 28-day discard period as per manufacturer instructions. |
Report Facts
Residents served: 48
License capacity: 100
Special care unit capacity: 30
Special care unit residents served: 13
Hospice current residents: 4
Residents age 60 or older: 46
Residents with mobility need: 22
Inspection Report
Renewal
Census: 39
Capacity: 100
Deficiencies: 11
Feb 8, 2023
Visit Reason
The inspection was conducted as a renewal review of the Heartis Bucks County facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The report details multiple deficiencies related to staff dementia training, emergency procedure submissions, medical evaluations, medication management, and documentation. All deficiencies have documented plans of correction with completion dates and have been implemented by the time of the report.
Deficiencies (11)
| Description |
|---|
| Staff person A did not have a dementia-specific training record on file. |
| The residence’s written emergency procedures had not been reviewed, updated, and submitted to the local emergency management agency since 01/21/2022. |
| Medical evaluation for resident #1 did not include an indication that a tuberculin skin test had been administered with negative results within 2 years; resident #6 had incorrect medical evaluation documentation. |
| Medication prescribed for resident #2 was found in the medication cart after the resident had passed away. |
| Opened medications (eye drops and insulin pens) were stored without open/discard after dates. |
| Medications in the SDCU unit medication cart were not properly labeled. |
| Resident #4's blood glucose readings were not documented accurately and did not match the glucometer log. |
| Medication administration records (MAR) did not consistently document medication administration despite count sheets being signed. |
| Resident #5 was administered medication twice in one day contrary to prescriber’s orders. |
| Staff person B lacked a record of an annual practicum for medication administration certification for 2022. |
| Resident #7's written cognitive preadmission screening was not dated. |
Report Facts
License Capacity: 100
Residents Served: 39
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 12
Hospice Current Residents: 2
Waking Staff: 38
Total Daily Staff: 51
Residents Age 60 or Older: 39
Residents with Mobility Need: 12
Inspection Report
Complaint Investigation
Census: 24
Capacity: 100
Deficiencies: 1
Jun 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation on 06/15/2022 to review compliance with regulations and assess the submitted plan of correction.
Findings
The facility was found to have administered PRN medication to a resident without proper documentation of symptoms or need, specifically by one medication technician on certain evenings. The facility submitted a plan of correction which was accepted and fully implemented by 04/21/2023, including staff in-service and alternative de-escalation training.
Complaint Details
The visit was complaint-related. The complaint involved improper administration and documentation of PRN medication to Resident #1. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident #1 was administered PRN medication without documented symptoms or observed need, and only by one medication technician on certain evenings. |
Report Facts
License Capacity: 100
Residents Served: 24
Special Care Unit Capacity: 30
Special Care Unit Residents Served: 11
Current Hospice Residents: 1
Residents Age 60 or Older: 24
Residents with Mobility Need: 11
Total Daily Staff: 35
Waking Staff: 26
Inspection Report
Follow-Up
Census: 15
Capacity: 100
Deficiencies: 4
Mar 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility to review compliance and plan of correction submissions.
Findings
The inspection identified deficiencies related to failure to provide required assistance with activities of daily living, neglect and abuse due to inadequate staffing and call bell system failures, and improper narcotic medication storage and counting procedures. Plans of correction were submitted and accepted with specified completion dates.
Deficiencies (4)
| Description |
|---|
| Resident #1 did not receive required assistance with transfers in and out of bed on 3/18/22 as indicated in the resident’s assessment and support plan. |
| Resident #1 was neglected when Staff Member A left early without notifying administrative staff, leaving only one staff member for 15 residents, including residents with mobility needs. |
| Resident #1's call bell pendant was not working properly, failing to alert staff when pressed. |
| Failure to properly count narcotic medications on the cart prior to shift change as required by facility policy. |
Report Facts
Residents served: 15
License capacity: 100
Staffing: 22
Waking staff: 17
Special care unit capacity: 15
Special care unit residents served: 6
Residents with mobility needs: 7
Residents with physical disability: 1
Inspection Report
Follow-Up
Census: 15
Capacity: 100
Deficiencies: 4
Mar 28, 2022
Visit Reason
The inspection visit was conducted as a follow-up to verify that the submitted plan of correction from a prior incident review was fully implemented.
Findings
The report details the acceptance and implementation of corrective actions addressing deficiencies in ADL assistance, abuse/neglect, furniture and equipment functionality, and medication storage procedures. The facility demonstrated compliance with the plan of correction as of the follow-up date.
Deficiencies (4)
| Description |
|---|
| Resident did not receive required assistance with transfers in and out of bed as indicated in the resident’s assessment and support plan. |
| Staff Member A left the residence early without notifying administrative staff, leaving insufficient staff to care for residents, resulting in neglect of a resident who was found sleeping in a wheelchair. |
| Resident call bell was not working properly, failing to alert staff when pressed. |
| Failure to properly count narcotic medications at shift change due to absence of Staff Member A during count. |
Report Facts
Residents served: 15
License capacity: 100
Residents with mobility needs: 7
Residents aged 60 or older: 15
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