Inspection Report
Complaint Investigation
Census: 49
Capacity: 86
Deficiencies: 7
Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations at the facility.
Findings
Multiple deficiencies were found including denial of resident record access, use of restraints by a private duty aide, unqualified direct care staff, unlocked poisonous materials accessible to residents, prohibited procedures involving restraints, incomplete dietary assessments, and missing death certificates in resident records. Plans of correction were accepted and implemented by early June 2025.
Complaint Details
The visit was complaint-related as indicated by the inspection information section. The complaint involved issues such as unauthorized restraints and denial of access to resident records. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (7)
| Description |
|---|
| Staff person denied resident's designated person access to the resident's record. |
| Resident was restrained with an unauthorized waistband belt by a private duty aide. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Poisonous materials (toothpaste labeled 'contact poison control') were unlocked and accessible to residents not assessed as capable of safe use. |
| Prohibited procedure: private duty aide strapped resident to wheelchair with waistband belt. |
| Resident's assessment and support plan did not document how restricted lactose dietary need would be met. |
| Resident record did not include the death certificate after resident expired in the home. |
Report Facts
License Capacity: 86
Residents Served: 49
Memory Care Unit Capacity: 26
Memory Care Unit Residents Served: 23
Hospice Current Residents: 2
Resident with Mobility Need: 35
Resident 60 Years or Older: 49
Resident Records Deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided education on residents' rights, restraint policy, and regulations; led in-service on obtaining death certificates. | |
| Resident Care Director | Responsible for corrective actions related to restraints, dietary assessments, and audits of private duty aides. | |
| Business Office Director | Conducted audits of associate files and implemented checklists for credential verification and move-out documentation. | |
| Reflections Director/Resident Services Supervisor | Responsible for daily rounds to ensure poisonous materials are locked and inaccessible. |
Inspection Report
Monitoring
Census: 40
Capacity: 86
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was a partial, announced visit conducted for new monitoring purposes at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 68
Waking Staff: 51
License Capacity: 86
Residents Served: 40
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 21
Residents Age 60 or Older: 40
Residents with Mobility Need: 28
Inspection Report
Renewal
Census: 45
Capacity: 86
Deficiencies: 8
Aug 19, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/19/2024.
Findings
The report found multiple deficiencies including issues with resident contract signatures, ceiling water damage, incomplete first aid kits, inoperable bedside lamps, outdated food labeling, menu posting, medication availability, and record entry legibility. All deficiencies had plans of correction accepted and were implemented by 10/22/2024.
Deficiencies (8)
| Description |
|---|
| Resident #1's contract contained a statement acknowledging receipt of resident rights, but the resident's signature was effaced with correction fluid. |
| One ceiling tile was removed due to water damage from a roof leak, with a bucket placed in the hallway to contain leaking. |
| The first aid kit in the kitchen and behind the front desk did not include a thermometer; a complete first aid kit was not located. |
| The bedside lamp for the resident in room 215 could not be turned on because it was unplugged. |
| Tupperware containers of corn and tuna in the kitchen refrigerator were labeled but undated. |
| The home's menu for the week of 8/18-8/24/2024 was posted, but the menu for the week in advance was not posted. |
| Medications prescribed for Resident #2 and Resident #3 were not available on the medication cart on 8/19/2024. |
| Correction fluid was used on Resident #1's signature on the list of resident rights in the resident's contract. |
Report Facts
Residents Served: 45
License Capacity: 86
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 45
Residents with Physical Disability: 32
Total Daily Staff: 45
Waking Staff: 34
Inspection Report
Follow-Up
Census: 24
Capacity: 86
Deficiencies: 3
Jul 10, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to failure to report suspected resident abuse, failure to report a significant fall injury, and incomplete cognitive preadmission screening for a resident admitted to the secured dementia care unit. Plans of correction were accepted and implemented.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected verbal and physical abuse of residents involving resident #1 and #2 to the Area Agency on Aging. |
| Failure to report an unwitnessed fall resulting in a closed fracture of multiple ribs of resident #1 to the Department within 24 hours. |
| Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to the secured dementia care unit for resident #2. |
Report Facts
License Capacity: 86
Residents Served: 24
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 8
Total Daily Staff: 32
Waking Staff: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations | Educated Executive Director and Resident Care Director on reporting requirements and regulatory compliance | |
| Executive Director | Verbalized lack of understanding of reporting regulations related to abuse and injury reporting | |
| Resident Care Director | Educated on reporting requirements and regulatory compliance |
Inspection Report
Monitoring
Census: 21
Capacity: 86
Deficiencies: 6
Jun 26, 2023
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes on 06/26/2023.
Findings
The inspection identified multiple deficiencies including missing emergency telephone numbers in resident bedrooms, improper freezer temperatures, outdated food items, medication administration documentation errors, failure to follow prescriber's orders, and incomplete resident record content. Plans of correction were accepted and implemented with ongoing audits and retraining.
Deficiencies (6)
| Description |
|---|
| No emergency telephone numbers including nearest hospital and fire department posted on or by telephones in bedrooms 202 and 406. |
| Memory care freezer temperature was 6°F and walk-in freezer temperature was 10°F, exceeding required limits. |
| Open and undated bags of food (Porcini Mushrooms, Spaghetti, Rice) found in dry food storage. |
| Medication administration records lacked initials of staff administering medication and documentation inconsistencies for multiple residents. |
| Failure to follow prescriber's orders including missed medication administrations and double dosing documented on controlled substance log. |
| Resident records missing hair color, eye color, and identifying marks. |
Report Facts
License Capacity: 86
Residents Served: 21
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 1
Residents Age 60 or Older: 21
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Rice | Executive Director | Named as responsible party for medication administration and record content deficiencies and related corrective actions. |
| Rattana Herman | Resident Service Specialist | Named in relation to medication administration deficiency and corrective actions. |
Inspection Report
Capacity: 22
Deficiencies: 0
Feb 16, 2023
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 02/16/2023 for the facility THE RESIDENCE AT BALA CYNWYD.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 22
Residents Served: 0
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