Inspection Reports for The Bridges at Bent Creek
2100 Bent Creek Blvd, Mechanicsburg, PA 17050, United States, PA, 17050
Back to Facility ProfileDeficiencies per Year
28
21
14
7
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Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 93
Capacity: 130
Deficiencies: 21
Sep 17, 2025
Visit Reason
The inspection was an unannounced renewal licensing inspection conducted on September 17-18, 2025, to assess compliance with Pennsylvania Department of Human Services regulations for The Bridges at Bent Creek.
Findings
Multiple violations were found including failure to post license revocation notice, expired boiler certificate, incomplete staff training, unsafe bedside mobility devices, malfunctioning call bell system, sanitary issues, missing emergency telephone numbers, improper food storage, presence of prohibited portable space heater, medication storage and administration deficiencies, incomplete resident assessments and support plans, and record entry issues.
Deficiencies (21)
| Description |
|---|
| License revocation notice dated 5/9/25 was not posted in a conspicuous and public place in the home. |
| Certificate of operation for the home's boiler expired on 8/25/25. |
| Staff Member A and B did not receive required annual training on resident needs and safe management techniques during training year 2024. |
| Staff Member A and B did not receive training in fire safety and Older Adult Protective Services Act during training year 2024. |
| Call bell system pendants failed to send signals to staff pagers; bedside mobility devices on residents 4 and 5 posed entrapment hazards. |
| Feces was present on the garbage can lid in resident room 149. |
| Emergency telephone numbers for nearest hospital and fire department were not posted on or by telephones in bedrooms 245 and 255. |
| Food stored on floor: 7 oranges in walk-in refrigerator. |
| Outdated or undated food: open container of sour cream with cracked lid in walk-in refrigerator. |
| Home failed to notify local fire department of address, bedroom locations, and evacuation assistance needs since 5/2/21. |
| Portable space heater found in bathroom of resident room 118. |
| Sleeping-hour fire drills were conducted at approximately the same time on three occasions. |
| Medications and syringes were unlocked and accessible in resident 10's room; resident not assessed to self-administer. |
| Expired inhaler given to resident 7 on 9/18/25. |
| Discrepancies found between blood sugar readings in glucometers and medication administration records for residents 8 and 9. |
| Staff Member E administered medications without having initial medication administration training certification. |
| Resident 10's initial assessment was not completed within 15 days of admission. |
| Resident 6's support plan did not include necessary details about bedside mobility device; Resident 7's assessment lacked mechanical soft diet need. |
| Resident 10's initial support plan was not completed within 30 days of admission. |
| Resident 11's cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit. |
| Correction tape was used on resident 12's support plan entries, violating record entry requirements. |
Report Facts
License Capacity: 130
Residents Served: 93
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 14
Residents Age 60 or Older: 93
Residents with Mobility Need: 41
Staff Total Daily: 134
Staff Waking: 101
Oranges Stored on Floor: 7
Inspection Report
Complaint Investigation
Census: 93
Capacity: 130
Deficiencies: 8
Aug 25, 2025
Visit Reason
The inspection was conducted as a complaint and monitoring visit to assess compliance with licensing regulations at The Bridges at Bent Creek.
Findings
Multiple violations were found including failure to report incidents of resident-to-resident abuse, direct care staff lacking required qualifications, refusal of medication not reported to prescribers, failure to follow prescriber's orders, delayed resident assessments, and incomplete resident support plans.
Complaint Details
The visit was complaint-related and monitoring in nature, with substantiation status not explicitly stated.
Deficiencies (8)
| Description |
|---|
| Failure to report incidents of resident-to-resident abuse to the Department within 24 hours. |
| Resident-to-resident verbal and physical abuse incidents occurred, including pushing and throwing water. |
| Direct care staff member lacked a high school diploma, GED, or active Pennsylvania nurse aide registry status. |
| Resident refusals of prescribed medications were not reported to the prescriber within 24 hours. |
| Medications were not administered as ordered by the prescriber on multiple occasions. |
| Resident initial assessments were not completed within 15 days of admission. |
| Resident additional assessments were not updated to reflect changes in behavior or condition. |
| Resident support plans did not document necessary medical and behavioral care supports. |
Report Facts
License Capacity: 130
Residents Served: 93
Staffing Hours: 134
Waking Staff: 101
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 14
Residents with Mobility Need: 41
Inspection Report
Monitoring
Census: 95
Capacity: 130
Deficiencies: 5
Jul 29, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 29, 2025, to assess compliance with licensing regulations for the facility.
Findings
The inspection identified multiple violations including cleanliness issues in the kitchen, uncovered food items in the refrigerator, incomplete medical evaluations, incomplete medication records, and unlocked medications accessible to residents. Plans of correction were directed with deadlines for remediation and education.
Deficiencies (5)
| Description |
|---|
| Loose food items including trash and ice cream chunks were found on the floor in the walk-in kitchen freezer. |
| A pitcher of iced tea, a cup of juice, and a small bowl of grapes were uncovered and stored in the dining room kitchenette refrigerator. |
| Resident #1’s medical evaluation form was missing the medical professional’s license number. |
| Resident #1’s medication record did not include a current list of medications, missing Desitin and Clindamycin Phosphate. |
| A bottle of Chlorhexidine Gluconate oral rinse was unlocked, unattended, and accessible in resident #2’s bathroom, who is not assessed to self-administer medication. |
Report Facts
License Capacity: 130
Residents Served: 95
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 14
Residents with Mobility Need: 41
Total Daily Staff: 136
Waking Staff: 102
Inspection Report
Complaint Investigation
Census: 98
Capacity: 130
Deficiencies: 14
Jun 17, 2025
Visit Reason
The inspection was conducted as a complaint, incident, and monitoring investigation with an unannounced partial inspection.
Findings
Multiple violations were found including breaches of resident record confidentiality, abuse and neglect related to wound care and resident safety, insufficient staffing during overnight hours, unsafe heat sources, failure to meet fire drill evacuation time requirements, incomplete medical evaluations, medication storage and administration errors, and incomplete resident assessments and support plan signatures.
Complaint Details
The inspection was complaint-driven, incident-related, and included monitoring. Specific complaints involved neglect, abuse, inadequate wound care, medication errors, and staffing concerns.
Deficiencies (14)
| Description |
|---|
| Resident records were left unlocked and accessible without proper authorization. |
| Resident #2 suffered worsening foot wounds due to inadequate wound care and neglect. |
| Resident #3 pushed resident #4 causing falls and injuries. |
| Insufficient overnight staffing to meet residents' needs and failure to evacuate residents within safe fire drill time. |
| Heat sources in the secured dementia care unit were not properly guarded, exposing residents to burns. |
| Fire drill evacuation time exceeded the maximum safe time specified by a fire safety expert. |
| Resident #2's initial medical evaluation lacked required information on body positioning and movement. |
| Resident #6's wound care was delayed and inadequate, leading to worsening pressure sores. |
| Medications were stored improperly with packaging left open to air. |
| Pharmacy label for resident #7's medication did not reflect current administration instructions. |
| Controlled substance record discrepancies for resident #8's Morphine Sulfate. |
| Multiple residents did not receive prescribed medications as ordered, including timing errors. |
| Resident #6's assessment was not updated to reflect significant changes in condition. |
| Support plans for residents #2 and #11 were not signed by required parties. |
Report Facts
License Capacity: 130
Residents Served: 98
Residents in Secured Dementia Care Unit: 21
Residents with Mobility Needs: 33
Total Daily Staff: 131
Waking Staff: 98
Fire Drill Evacuation Time: 21.6
Medication Discrepancy: 1
Inspection Report
Complaint Investigation
Census: 101
Capacity: 130
Deficiencies: 22
Mar 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 03/24/2025 through 03/27/2025 at The Bridges at Bent Creek.
Findings
The inspection revealed multiple violations including failure to provide immediate access to records, failure to report incidents, medication administration errors, confidentiality breaches, unsafe storage of poisonous materials, hot water temperature violations, unsafe exterior conditions, improper food handling, incomplete medical evaluations, failure to secure preventative care, medication errors, improper medication storage and destruction, incomplete resident assessments and support plans, and failure to post key-locking device instructions. The facility's license was revoked due to gross incompetence, negligence, and misconduct.
Complaint Details
The inspection was complaint-driven, triggered by allegations of violations related to resident care, medication administration, and facility compliance. The complaint investigation found substantiated violations leading to license revocation.
Deficiencies (22)
| Description |
|---|
| Delayed provision of resident medication administration records to Department agents. |
| Failure to report a large wound and related incident to the Department within required timeframes. |
| Failure to maintain confidentiality of resident medication orders and controlled substance count books. |
| Resident medications and treatments were not administered according to prescriber's orders. |
| Unlocked poisonous materials accessible to residents in memory care unit. |
| Hot water temperature exceeded 120°F in resident bathroom sink. |
| Exterior egress route was hazardous due to mulch surface, posing risk for residents using mobility devices. |
| Unlabeled and undated leftover food found in activity room refrigerator. |
| Resident medical evaluation lacked required information on body positioning and movement. |
| Failure to assist resident in securing preventative medical care as ordered by physician. |
| Medications administered by staff not trained or certified in medication administration. |
| Medications and syringes were left unlocked and accessible to residents. |
| Improper destruction of discontinued medications found in unlocked trash cans. |
| Medication administration records did not match actual medication dispensed. |
| Failure to document and report resident refusal of medication to prescriber. |
| Failure to follow prescriber's orders for medication administration and wound care treatments. |
| Failure to immediately report medication errors to resident, designated person, and prescriber. |
| Staff administering medications had not completed required annual medication administration training. |
| Resident assessments were not updated to reflect significant changes in condition or dietary needs. |
| Directions for operating key-locking devices were not conspicuously posted near Secure Dementia Care Unit exits. |
| Resident support plan did not include use of assistive device observed during inspection. |
| Resident death certificates were missing from resident records. |
Report Facts
Inspection dates: 4
License capacity: 130
Residents served: 101
Secured Dementia Care Unit capacity: 31
Residents served in dementia unit: 23
Hospice residents: 14
Staffing hours: 135
Waking staff hours: 101
Residents with mobility needs: 34
Residents with physical disability: 1
Residents aged 60 or older: 101
Medication doses discrepancy: 3
Residents with missing death certificates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the revocation letter |
| Staff member B | Administered medications without current training and improperly destroyed medications | |
| Staff member G | Not certified in medication administration, cleaned and dressed resident #3's wound | |
| Staff member H | Administered medications without completing annual medication administration training | |
| Staff member I | Administered medications without completing required annual practicum observations | |
| Staff member J | Not qualified to administer medications but administered medications | |
| Staff member K | Did not complete Department-approved medication administration course but administered medications | |
| Executive Director | Named in multiple findings related to training, audits, and corrective actions | |
| Director of Wellness | Named in multiple findings related to training, audits, medication administration, and corrective actions | |
| Director of Marketing | Named in training and admission criteria education | |
| Memory Care Director | Named in training, audits, and securing hazardous materials | |
| Business Office Manager | Responsible for resident-home contract signature compliance | |
| Maintenance Director | Responsible for hot water temperature checks and posting door codes |
Inspection Report
Follow-Up
Census: 95
Capacity: 130
Deficiencies: 3
Jan 7, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to deficiencies in resident assessments, preadmission screenings, and admission support plans.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies in initial resident assessments, cognitive preadmission screenings, and admission support plans for residents in the secured dementia care unit. Continued compliance is required.
Deficiencies (3)
| Description |
|---|
| An assessment was not completed for a resident within 15 days of admission. |
| A written cognitive preadmission screening was not completed for a resident admitted to the secured dementia care unit. |
| The resident's initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
License Capacity: 130
Residents Served: 95
Secured Dementia Care Unit Capacity: 31
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 18
Residents Age 60 or Older: 95
Residents with Mobility Need: 49
Inspection Report
Renewal
Census: 92
Capacity: 130
Deficiencies: 11
Aug 27, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license, including an unannounced full inspection on 08/27/2024 and 08/28/2024.
Findings
The inspection identified multiple deficiencies including staff qualifications, training, resident safety equipment, sanitary conditions, resident access to bedrooms, food protection, annual medical evaluations, medication storage, documentation accuracy, and support plan timeliness. All deficiencies had plans of correction accepted and were implemented or scheduled for completion by the end of 2024.
Deficiencies (11)
| Description |
|---|
| Staff member A did not have a high school diploma, GED or active registry status on the Pennsylvania nurse aide registry. |
| Staff members A and B did not receive the required annual Medication self-administration training during the 2023 training year. |
| The bed of resident #5 had an enabler bar with no covering and a measured opening of 12 inches x 6 inches, posing an entrapment risk. |
| Bloodstain and smeared blood observed on carpet floor in resident #6's room; smeared fecal matter observed on toilet seat, bowl, and shower floor in resident #7's bathroom. |
| Several resident rooms in the Secure Dementia Care Unit were locked, prohibiting residents from freely accessing their rooms. |
| Uncovered serving cups containing vanilla ice cream and an opened, uncovered box of croissant buns were found in the kitchen, not protected from contamination. |
| Resident #6's most recent medical evaluation was not documented; previous evaluation date also missing. |
| Resident #1 self-administered medications stored unlocked and unattended in their room. |
| Resident #4's Medication Administration Record had incorrect blood sugar documentation compared to glucometer readings. |
| Resident #8 was admitted without a completed preadmission screening form. |
| Resident #1's initial support plan was completed 20 days after admission to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 130
Residents Served: 92
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 18
Residents with Mobility Need: 44
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 78
Capacity: 130
Deficiencies: 5
May 2, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BRIDGES AT BENT CREEK facility on 05/02/2024.
Findings
The inspection found multiple deficiencies related to incomplete preadmission screening forms, missing annual resident assessments, outdated support plans regarding hospice services, lack of timely medical evaluations prior to admission to the secured dementia care unit, and missing written cognitive preadmission screenings within 72 hours prior to admission to the secured dementia care unit. Plans of correction were accepted and implemented with proposed completion dates mostly by 06/30/2024 and verified as implemented by 07/01/2024.
Complaint Details
The inspection was complaint-driven and included incident investigation. The submitted plan of correction was reviewed and determined to be fully implemented as of 05/02/2024.
Deficiencies (5)
| Description |
|---|
| Resident preadmission screening form missing determination that resident needs can be met and several required sections. |
| Resident did not have an annual assessment from 10/08/2021 until 04/05/2023. |
| Resident's support plan did not indicate hospice services despite resident being on hospice. |
| Resident did not have a medical evaluation by a physician, physician’s assistant, or certified registered nurse practitioner within 60 days prior to admission to the secured dementia care unit. |
| Resident did not have a written cognitive preadmission screening completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 130
Residents Served: 78
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 17
Residents with Mobility Need: 45
Residents with Physical Disability: 2
Staffing Hours - Total Daily Staff: 123
Staffing Hours - Waking Staff: 92
Inspection Report
Complaint Investigation
Census: 67
Capacity: 130
Deficiencies: 7
Oct 3, 2023
Visit Reason
The inspection was a complaint and incident investigation conducted as an unannounced partial inspection on 10/03/2023.
Findings
The inspection found multiple deficiencies including failure to report suspected resident abuse timely, medication errors involving missed doses of Methimazole for Resident #1, unreported medication errors, resident-to-resident abuse incidents, inadequate supervision in the secured dementia care unit, and incomplete medication administration training for staff. Plans of correction were directed and accepted with follow-up dates.
Complaint Details
The inspection was complaint-driven, investigating incidents including alleged resident-to-resident abuse and medication errors. The complaint was substantiated with findings of abuse and medication administration violations.
Deficiencies (7)
| Description |
|---|
| Failure to immediately report suspected resident-to-resident abuse to the local area agency on aging. |
| Failure to report medication errors for Resident #1 involving missed doses of Methimazole from 8/13/2023 to 8/18/2023. |
| Resident-to-resident abuse incident resulting in injuries to residents. |
| Heat source in secured dementia care unit kitchen area was 190°F with no protective guards and an open unattended door. |
| Failure to follow prescriber's orders for Resident #1 by not administering prescribed Methimazole due to medication unavailability. |
| Failure to immediately report medication errors to resident, designated person, and prescriber within 24 hours. |
| Staff Member A did not complete required medication administration annual practicum and was removed from medication administration until completion. |
Report Facts
License Capacity: 130
Residents Served: 67
Secured Dementia Care Unit Capacity: 31
Residents Served in Secured Dementia Care Unit: 21
Current Hospice Residents: 15
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Medication Missed Days: 6
Total Daily Staff: 102
Waking Staff: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in deficiency for not completing medication administration annual practicum and removed from medication administration until completion. | |
| Staff Member B | Observed resident-to-resident abuse incident and reported findings. |
Inspection Report
Renewal
Census: 62
Capacity: 130
Deficiencies: 11
Jul 6, 2023
Visit Reason
The inspection was conducted as a renewal and provisional review of the facility license.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were identified including failure to post current license regulations, lack of thermometer in freezer, failure to submit emergency procedures to local EMA, obstruction of emergency exit, incomplete evacuation during fire drill, medication self-administration assessment issues, unsecured medications, missed medication administration, and incomplete support plan documentation and signatures.
Deficiencies (11)
| Description |
|---|
| PA Chapter 2600 Regulations were not posted in a conspicuous and public place in the home. |
| No thermometer in the freezer section of the refrigerator located in the Bistro Area. |
| Emergency Preparedness Procedure not submitted to local Emergency Management Agency since 08/09/2021. |
| Housekeeping cleaning cart obstructing emergency exit next to resident room 174. |
| During fire drill on 06/20/2023, only 25 of 61 residents were evacuated. |
| Resident 8 had unassessed self-administered medication (Tums Antacids) in bathroom. |
| Resident 1's Nystatin Topical Powder was observed unattended and accessible on medication cart. |
| Resident 7 did not receive prescribed Buspirone on 06/17/2023; Resident 6 received incorrect dosage of Rivastigmine patch during June. |
| Support plans did not include if resident is able to safely use and avoid poisonous materials for Residents 3 and 4. |
| Residents who participated in support plan development did not sign and date the plans timely (Residents 2, 3, and 5). |
| Resident 7's assessment and support plans lacked documentation regarding need for continued secure dementia care. |
Report Facts
License Capacity: 130
Residents Served: 62
Residents in Secured Dementia Care Unit: 16
Hospice Residents: 13
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Residents 60 Years or Older: 62
Residents Evacuated During Fire Drill: 25
Residents Present During Fire Drill: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the cover letter regarding plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 130
Deficiencies: 4
Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 02/09/2023, 02/17/2023, and 02/21/2023 to review compliance and verify the submitted plan of correction.
Findings
Multiple deficiencies were found including unsecured poisonous materials accessible to residents, unsanitary conditions with strong urine odors in resident rooms, missing conspicuous posting of key-locking device operation instructions, and unsecured confidential resident records. The submitted plan of correction was accepted and fully implemented by 03/10/2023.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission required and accepted. The plan was fully implemented by 03/10/2023.
Deficiencies (4)
| Description |
|---|
| Poisonous materials were found unlocked and accessible in residents' bathrooms despite labels warning of medical attention if ingested. |
| Strong odor of urine and severely stained furniture noted in residents' bedrooms indicating unsanitary conditions. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the Secure Dementia Care Unit door, and only one of two keypads was operational. |
| Controlled substances binder and a 'shift to shift' binder containing protected health information were unlocked and accessible, risking unauthorized access. |
Report Facts
License Capacity: 130
Residents Served: 65
Secured Dementia Care Unit Capacity: 31
Residents Served in Secured Dementia Care Unit: 16
Total Daily Staff: 102
Waking Staff: 77
Residents with Mobility Need: 37
Inspection Report
Complaint Investigation
Census: 71
Capacity: 130
Deficiencies: 10
Nov 15, 2022
Visit Reason
The inspection was conducted due to a complaint, incident, and interim review at the facility.
Findings
Multiple deficiencies were identified including delayed reporting of alleged resident abuse, failure to report incidents timely to the Department, missing resident signatures on contracts and support plans, lack of CPR/First Aid certified staff during certain shifts, improper medication storage and administration, and missing documentation for admission to the secured dementia care unit.
Complaint Details
The visit was complaint-related involving allegations of resident abuse and incident reporting failures. The abuse allegation involved a staff member accused of pushing Resident #1, which was not reported timely to the local area agency or the Department. Additional incidents involved delayed reporting of hospital treatment for Resident #4.
Deficiencies (10)
| Description |
|---|
| Delayed reporting of alleged abuse of Resident #1 to the local area agency on aging. |
| Failure to report abuse incident involving Resident #1 to the Department within 24 hours. |
| Failure to report hospital treatment of Resident #4 after an unwitnessed fall to the Department timely. |
| Resident-home contract for Resident #2 was not signed by the resident. |
| No staff certified in CPR and/or First Aid present during specified shifts on 11/11/2022 and 11/12/2022. |
| Discontinued medication found in medication cart for Resident #2. |
| Glucometers for Residents #5, #6, and #7 were not calibrated to the correct time. |
| Resident #3's prescribed PRN medication was not administered as ordered. |
| Resident #2 did not sign the support plan despite participation in its development. |
| No documentation that Resident #2 or designated person objected to admission to the secured dementia care unit. |
Report Facts
License Capacity: 130
Residents Served: 71
Secured Dementia Care Unit Capacity: 31
Residents Served in Dementia Unit: 20
Hospice Residents: 17
Residents with Mobility Need: 29
Total Daily Staff: 100
Waking Staff: 75
Inspection Report
Renewal
Census: 81
Capacity: 130
Deficiencies: 28
Sep 12, 2022
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation of The Bridges at Bent Creek facility.
Findings
The inspection identified multiple violations including failure to post current licenses, delayed reporting of resident abuse, inadequate staffing hours, lack of certified first aid/CPR staff, unsafe resident equipment, unsecured poisonous materials, unsanitary conditions, medication storage and administration issues, incomplete resident medical evaluations and support plans, and missing documentation in resident records.
Complaint Details
The inspection included complaint and incident investigations related to resident abuse and failure to report incidents timely. Specific abuse incidents involved resident-to-resident physical abuse and failure to report to protective services within required timeframes.
Deficiencies (28)
| Description |
|---|
| Licensing Inspection Summaries were not posted in a conspicuous and public place in the home. |
| Failure to report allegations of resident-to-resident abuse to Older Adult Protective Services within 48 hours. |
| Failure to report an incident of abuse to the Department within 24 hours. |
| Resident-home contract was not signed by the resident. |
| Resident #2 punched Resident #3 in the abdomen; abuse violation. |
| Only 4 of 22 residents in the Secured Dementia Care Unit received showers as scheduled. |
| Direct care staff hours were below the required minimum on 9/6/2022 and 9/9/2022. |
| Less than 75% of personal care service hours were provided during waking hours on 9/6/2022 and 9/9/2022. |
| No staff certified in First Aid and CPR were present from 9/4/2022 to 9/5/2022. |
| Enabler bars on residents' beds were uncovered, creating potential hazards. |
| Poisonous materials were unlocked and accessible to residents in the Secured Dementia Care Unit. |
| Strong urine odor and black mold observed in facility areas. |
| Trash outside the home was not kept in covered receptacles. |
| Exterior building hazards including torn metal flashing with sharp edges. |
| Accumulation of lint in dryer lint trap. |
| Resident's pet had expired rabies vaccination. |
| Fire drills were postponed due to COVID-19 outbreak without proper notification. |
| Resident medical evaluations missing required information such as ability to self-administer medications and evaluation dates. |
| Medications were not available in the home as prescribed for multiple residents. |
| Medication administration records lacked diagnosis or purpose for medications. |
| Medication was not administered as prescribed (Furosemide delayed administration). |
| Resident support plans did not reflect assessed needs or behaviors. |
| Support plans were missing required signatures from residents and assessors. |
| Medical evaluation for secured dementia care unit residents was not current or missing. |
| Written cognitive preadmission screening was not completed for secured dementia care unit resident. |
| No documentation that resident or designated person objected to admission to secured dementia care unit. |
| Admission support plan was not completed within required timeframe. |
| Resident records missing identifying marks, religious affiliation, or recent photographs. |
Report Facts
License Capacity: 130
Residents Served: 81
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 23
Hospice Residents: 15
Residents with Mobility Need: 45
Direct Care Hours Required: 122
Direct Care Hours Provided: 109
Direct Care Hours Provided: 100
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 3
Calculated Fine: 355
Calculated Fine: 213
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 28, 2022
Visit Reason
The document is a follow-up review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to determine if the submitted plan of correction for the facility was fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Report Facts
Inspection dates: Review dates mentioned are 07/28/2022 and 08/02/2022
Inspection Report
Complaint Investigation
Census: 85
Capacity: 130
Deficiencies: 3
Jul 6, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BRIDGES AT BENT CREEK facility on 07/06/2022 and 07/07/2022.
Findings
The inspection found multiple deficiencies including failure to provide 30 days advance written notice of contract changes to Resident #1, delayed staff response to Resident #2's call for assistance resulting in dignity and respect violations, and inaccurate documentation in Resident #2's support plan regarding medical needs. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, investigating issues including billing notice failure and treatment delays. The complaint was substantiated with findings of deficiencies and corrective actions implemented.
Deficiencies (3)
| Description |
|---|
| Resident #1 was not provided at least 30 days advanced written notice of the change to the resident-home contract regarding rates increase. |
| Resident #2 waited over 2 hours for staff assistance after activating a call bell, resulting in failure to treat the resident with dignity and respect. |
| The Resident Assessment Support Plan (RASP) for Resident #2 did not reflect the need for body repositioning and movement due to medical condition. |
Report Facts
License Capacity: 130
Residents Served: 85
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 14
Residents Diagnosed with Mental Illness: 31
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 34
Residents with Physical Disability: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gloria Emick | Signed letter regarding plan of correction implementation | |
| Executive Director | Involved in examining billing issue, issuing refunds, education, and corrective actions | |
| Regional Director of Operations | Assisted in examining billing issue and corrective actions | |
| Staff Member A | Responded to Resident #2 after 2-hour delay | |
| Business Office Director | Received education regarding billing notice documentation |
Inspection Report
Follow-Up
Census: 94
Capacity: 130
Deficiencies: 8
Mar 1, 2022
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction related to complaint, incident, and interim reasons.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to fire safety orientation, staff training on resident rights and abuse reporting, medication storage, medication administration documentation, refusal of medication, and support plan signatures were addressed with education, audits, and procedural changes.
Complaint Details
The inspection was complaint-related, incident-related, and interim. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (8)
| Description |
|---|
| Staff Person A, a contracted employee, did not receive orientation on fire safety topics including evacuation procedures, fire drills, smoking safety, fire extinguishers, smoke detectors, and emergency telephone use. |
| Staff Person A did not complete required training on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled working hours. |
| Loose pills were found in medication carts Med Cart T1, Med Cart 2, and The Garden cart. |
| Discrepancies between residents' glucometer readings and medication administration records (MARs) were noted for multiple residents. |
| Resident 8 refused scheduled medication doses without documentation verifying prescriber notification. |
| Resident 2 was prescribed medication that was not administered due to unavailability in the home. |
| Resident 7's support plan was not signed by the resident, assessor, or responsible party. |
| Resident 10's care plan notes were unlocked, unattended, and accessible at the front desk of the home. |
Report Facts
License Capacity: 130
Residents Served: 94
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 22
Staffing Hours - Total Daily Staff: 134
Staffing Hours - Waking Staff: 101
Staffing Hours - Resident Support Staff: 0
Plan of Correction Follow-Up Dates: 3
Training Completion Dates: 2
Medication Audit Start Date: 1
Glucometer Audit Start Date: 1
Education Dates: 3
Chart Audit Start Date: 1
Inspection Report
Routine
Deficiencies: 0
Nov 8, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Capacity: 130
Deficiencies: 0
Oct 31, 2021
Visit Reason
The document is a renewal license issued in response to the facility's July 20, 2021 renewal application to operate the Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
The document grants a regular license to operate the Personal Care Home with a maximum capacity of 130 residents, including a Secure Dementia Care Unit with a capacity of 31. No findings of noncompliance or deficiencies are stated in this document.
Report Facts
Maximum capacity: 130
Secure Dementia Care Unit capacity: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding renewal license and Department process |
Inspection Report
Renewal
Census: 88
Capacity: 130
Deficiencies: 14
Sep 21, 2021
Visit Reason
The inspection was conducted as a full, unannounced licensing inspection with reasons including renewal and complaint investigation.
Findings
Multiple deficiencies were identified related to quality management, staffing, safety, medical evaluations, medication storage, and resident assessments. Plans of correction were accepted with specified completion dates.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. Specific substantiation status is not stated.
Deficiencies (14)
| Description |
|---|
| The most recent quality management review was conducted on 7/7/2020. |
| Staffing was inadequate during certain hours, with insufficient staff to meet evacuation needs. |
| Poisonous materials were unlocked and accessible in the secured dementia care unit. |
| Sanitary conditions were compromised by sharing of glucometers and incorrect blood glucose readings. |
| Grab bars were missing in the women's restroom near the mailboxes. |
| Medical evaluations for residents #5 and #6 did not include vital signs and dates of evaluation. |
| First aid kit in the vehicle was incomplete, missing scissors, tweezers, thermometer, and CPR shield. |
| Medications were not stored securely; loose pills were found in medication cart #2. |
| Glucose readings were incorrectly recorded in medication administration records for resident #9. |
| Resident assessments and support plans for residents #1, #3, and #4 were not completed timely. |
| Resident #7's sliding scale insulin treatment was not properly documented. |
| Resident #1 was admitted to the Secure Dementia Care Unit without documentation of initial support plan. |
| Resident-home contract was missing or incomplete for resident #1. |
| Annual support plan revision was not completed for resident #6. |
Report Facts
License Capacity: 130
Residents Served: 88
Secured Dementia Care Unit Capacity: 31
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 15
Inspection Dates: 3
Staffing: 121
Waking Staff: 91
Deficiency Completion Dates: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director or designee | Responsible for quality management plan and staffing corrections. | |
| Memory Care Director | Responsible for poisonous materials correction and medication storage. | |
| Wellness Director or designee | Responsible for sanitary conditions, medical evaluations, medication storage, and resident assessments. | |
| Director of Engineering or designee | Responsible for grab bar installation and first aid kit maintenance. | |
| Business Office Director, Memory Care Director, Executive Director or designee | Responsible for obtaining signatures and support plan documentation. |
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