Juniper Village at Bucks County Senior Living.

“Resident requiring total physical assistance with transferring, ambulating, and toileting was not helped out of bed to use the toilet as required, particularly overnight. Incontinent products changed only twice or less between 2:30 pm and 8:30 am, causing resident to wake soaked in urine and contributing to a persistent painful rash.”

“Staff person A was hired without a record of a criminal background check requested on or prior to the staff person's first day of work, in violation of criminal history check requirements.”

“Direct care staff person B did not receive training in medication self-administration during training year 2025, a required annual training topic.”

“Staff person B did not receive training in The Older Adult Protective Services Act during training year 2025, a required annual training topic. This is a repeated violation.”

“A call-bell device in a resident bathroom was disconnected and inoperable for resident use during the inspection at 10:10 am.”

“Resident's most recent medical evaluation was completed on a date, however the previous medical evaluation was completed more than one year prior, failing to meet the requirement for annual medical evaluations.”

“A resident prescribed a medication for application was not administered on two scheduled occasions because the medication was not available in the home, resulting in failure to follow the prescriber's orders.”

“Video cameras were present throughout the home recording at least 72 hours. Home rules posted at Memory Care entrance indicated monitoring but did not specify video recording. No postings were present at Personal Care unit entrances regarding camera monitoring and recording.”

“Staff person C did not receive required annual training during 2024 in the following areas: fire safety, emergency preparedness procedures, resident rights, Older Adult Protective Services Act, falls and accident prevention, and new population groups.”

“Current license inspection summary and chapter were not posted in a conspicuous and public place in the home's personal care unit.”

“Department agent requested access to the facility at 9:00 a.m. but staff did not make themselves available to assist the agent until 9:29 a.m., causing a 29-minute delay.”

“Resident over 60 years of age passed away; personal belongings were removed from room but refund check was not issued within the required 30-day timeframe.”

“Resident was discharged; the home did not issue a refund check within the required 30-day timeframe.”

“Staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, failing to meet required qualifications for direct care staff.”

“A resident in the memory care unit with known exit-seeking behavior eloped on an extremely cold day (temperatures between -14°F to -25°F) by following a visitor through the main doors. The resident was found outside 22 minutes later on a pathway to a parking lot, wearing inadequate clothing for the weather and displaying confusion. The facility lacked a specific policy or procedure for monitoring residents requiring extensive supervision beyond redirection and activity engagement.”

“Following an elopement incident where a resident exited the secured dementia care unit, no additional assessment was conducted to address the event or implement further support measures beyond the most recent annual assessment.”

“A resident was admitted to the Secure Dementia Care Unit on one date, but the initial support plan was not completed within 72 hours of admission or 72 hours prior to admission as required.”

“Resident hourly checks were left unlocked, unattended, and accessible to all residents, staff, and visitors on the reception desk in the Wellspring Unit, violating record confidentiality requirements.”

“A bedside mobility device in a resident room had an improper cover consisting of stocking-like material that could be pulled down through an expandable hole, leaving an opening of approximately 10 inches by 20 inches uncovered.”

“Medication cards were observed with punctured blister foil with medication still present in the spots, exposing the medication to contamination or improper sanitation.”

“A bottle of OTC medication was found in the Cottonwood medication cart at 2pm without being labeled with any resident's name or room number.”

“During fire drills held on 09/13/2024, 08/16/2024, 06/28/2024, and 05/31/2024, not all residents evacuated to a designated meeting place away from the building or within the fire-safe area as required.”

“Resident #1 was served grilled chicken sandwich on 08/28/2024 despite a prescribed diet of mechanical soft with ground meat and extra sauce and gravy, resulting in a choking incident where the food had to be dislodged by Heimlich maneuver.”

“Resident #2's Morphine medication signed out on 09/25/2024 lacked documented time of distribution. Resident #3's glucometer had no readings on 09/28/2024 and 09/29/2024, yet staff documented blood glucose readings of 129 and 112 respectively.”

“Resident #2 prescribed Morphine four times daily was not administered the 04:30 PM dose on 09/25/2024. Resident #3 prescribed accuchek once daily did not receive the test on 09/28/2024 and 09/29/2024.”

“Resident #4's annual assessment indicates need for short term memory assistance but no assessment was completed. The assessment and support plan also omit assessment of long term memory needs and ability to safely use or avoid poisonous materials.”

“During fire drills held on multiple dates (08:30 PM, 03:46 AM, 06:46 AM, and 02:19 PM), not all residents evacuated to a designated meeting place away from the building or within the fire-safe area as required.”

“A resident prescribed a mechanical soft diet with ground meat and extra sauce and gravy was found choking on a piece of chicken from a grilled chicken sandwich, indicating the prescribed dietary needs were not followed. The resident's diet was subsequently changed to minced and moist after the incident.”

“Staff failed to document the time a resident's prescribed Morphine was signed out. Additionally, a resident's accuchek glucose readings were not recorded on multiple dates, but readings were falsely documented in the level log by staff.”

“A resident prescribed medication four times daily at specified times was not administered the medication at 04:30 PM on a documented date. Additionally, a resident prescribed daily accuchek glucose monitoring did not have readings performed on multiple documented dates.”

“A resident's annual assessment indicated a need for short-term memory assessment but no such assessment was performed. The assessment and support plan also omitted required assessments of long-term memory needs and the ability to safely use or avoid poisonous materials.”

“A resident's record did not include documented dietary restrictions prior to a choking incident. The resident's most recent support plan indicated a mechanical soft diet with ground meat and extra sauce and gravy, but no diet communication form was on file prior to the incident. This is a repeat violation.”

“There were no paper towels, mechanical hand dryer or other sanitary means of hand drying in the common shower room on the second floor.”

“A copy of 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 with a manufacturer's label warning to keep out of reach of children was unlocked, unattended, and accessible to residents at the front door of the home's secure dementia care unit. Residents of the unit, including resident #1, have been assessed incapable of recognizing and using poisons safely. This is a repeat violation from 10/16/23.”

“A copy of 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 with a manufacturer's label warning to keep out of reach of children was unlocked, unattended, and accessible to residents at the front door of the home's secure dementia care unit. Residents of the unit, including resident #1, have been assessed incapable of recognizing and using poisons safely. This is a repeat violation from 10/16/23.”

“There were no paper towels, mechanical hand dryer or other sanitary means of hand drying in the common shower room on the second floor.”

“The scale used to weigh all personal care and memory care unit residents was broken since July 2023.”

“Two bottles of McKesson Premium Hand Sanitizer labeled 'Please keep out of reach of children' were unlocked, unattended, and accessible to residents in the Secured Dementia Care Unit. Not all residents have been assessed as capable of safely recognizing and using poisons.”

“Staff member A did not provide documentation of 24 hours of annual training. The last training provided was from May 2022.”

“Resident 1's support plan specifies that the resident is unable to do their own laundry but is unclear how the facility will meet this service need.”

“A criminal background check could not be provided for staff member A.”

“Staff person A could not provide a license as a registered nurse, licensed practical nurse with one year of work experience, an associate's degree with 60+ credits from an accredited college, or a nursing home administrator license, despite the home serving 43 residents.”

“Staff member A was not present in the home for an average of 20 hours per week in each calendar month. Multiple weeks across April through October 2023 lacked an administrator on site for the required minimum hours.”

“Staff member A did not provide documentation of completion of the 100-hour standardized Department-approved administrator training course.”

“Two residents (#1 and #2) did not have a resident-home contract in place prior to or within 24 hours of admission.”

“Resident #3's resident-home contract was not signed by the resident. This is a repeat violation from 6/29/21.”

“Records for residents #1, #2, and #3 did not contain a signed statement from each resident acknowledging receipt of resident rights and complaint procedures. This is a repeat violation from 6/29/21.”

“Sanitation issues were found in the kitchen during a pest control inspection, including dirty floor drains, floor under the cook/steamline, and trash cans that needed cleaning to prevent pest attraction.”

“Evidence of infestation was found: bedbugs in room 206 and mice in the kitchen.”

“Residents #1, #2, and #3 had not been educated regarding their right to question or refuse medication if they believe there may be a medication error.”

“Resident #3's support plan did not document the need for an enabler bar, which was determined necessary for the resident.”