Blue Bell Place.

“Resident medical information and glucose monitoring logs were unlocked, unattended, and accessible in the medication room in the secure dementia care unit, violating confidentiality requirements.”

“Direct care staff persons A and B did not receive medication self-administration training during the training year, which is a required training topic for annual staff training.”

“A small blue plastic spray bottle labeled only 'cleaning spray' in marker was located in a credenza in the memory care dining room, with staff unable to determine its contents, violating requirements that poisonous materials be stored in original, labeled containers.”

“Odor Ban disinfectant spray bearing a poison control warning label was stored on top of the juice dispenser in the secure dementia care unit kitchen, violating requirements that poisonous materials be stored separately from food and food preparation surfaces.”

“Odor Ban disinfectant spray was not kept locked and inaccessible to residents in the secure dementia care unit kitchen.”

“A resident's record did not include a medical evaluation for 2025, in violation of the annual medical evaluation requirement.”

“Two red stop signs were posted on double doors leading to an emergency exit from the secure dementia care unit, presenting an obstruction that may deter persons from using the exit in an emergency.”

“A discontinued medication (Ondansetron) was still present in the home's medication cart after being discontinued, violating the requirement to keep only current prescription medications.”

“A resident's medication blister pack had a punctured foil with medication exposed to contamination. Additionally, an expired medication bottle was found in the medication cart.”

“A sample prescription medication was found in the medication cart without written instructions for use from the prescriber.”

“Multiple residents' glucometer readings did not match readings entered on medication administration records (MAR), and one glucometer was not calibrated to the correct time, indicating deficiencies in medication storage and management procedures.”

“The home failed to report an incident (unwitnessed fall with head injury) to the Department within 24 hours. Resident 1 fell and was found with dried blood on 5/18/2025 at 8am, but the incident was not reported to the Department until 5/20/2025.”

“Resident 1 was neglected when two-hour wellness checks were not consistently performed. Staff completed checks at midnight and 4:30 am (when catheter was emptied), but no additional checks occurred until 8 am when the resident was found on the floor with a head injury.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, failing to meet minimum qualification requirements for direct care staff.”

“The facility's administrator completed only 15 hours of Department-approved training during the training year from July 2023 to June 2024, failing to meet the required minimum of 24 hours of annual training relating to job duties.”

“Multiple staff members did not receive required annual training in 2024: Staff Person B and D did not complete fire safety training; Staff Person C did not complete fire safety training or emergency preparedness procedures training. This was a repeat violation from prior dates 02/24/2025 and 03/18/2024.”

“Nineteen 5-gallon water bottles were found stored directly on the floor in the commercial laundry storage area instead of being stored off the floor.”

“No thermometer was present in the ice cream freezer located in the main kitchen, violating the requirement that thermometers be in all refrigerators and freezers.”

“Multiple food items in the main kitchen were not properly covered or sealed: two ice cream containers in the ice cream freezer, a bag of corn and bag of mixed vegetables in the walk-in freezer, and a bag of pork sausage links in the walk-in refrigerator.”

“A resident was physically injured during incontinence care when staff member rolled the resident toward the wall without proper lighting or positioning, resulting in a severely displaced distal humerus fracture. The resident resisted care and made a pained facial expression during the transfer.”

“Direct Care Staff Person A did not receive required annual training topics including medication self-administration, instruction on meeting resident needs, care for dementia/cognitive impairments, infection control and hygiene, personal care service needs, safe management techniques, and care for residents with mental illness.”

“Staff Person A did not receive required annual training in fire safety, emergency preparedness procedures and crisis response, resident rights, the Older Adult Protective Services Act, and falls and accident prevention.”

“The facility failed to report a physical altercation incident between two residents to the Department within 24 hours as required. Staff were notified that one resident hit another resident on the back of the head, but no report was made to the department.”

“A resident requiring assistance with reminders for eating, behaviors, and personal hygiene did not receive documented assistance as required by their assessment and support plan. Multiple instances documented including simultaneous breakfast and lunch reminders, delayed dinner reminders, missed breakfast reminders, and missed evening hygiene reminders on various dates.”

“Multiple instances of resident-to-resident abuse and neglect documented: a resident slapped another resident on the head while they were in a wheelchair; a resident punched another resident's arm; a resident verbally aggressed toward another resident. Additionally, assurance checks required in a resident's support plan were not completed as scheduled on multiple dates, missing checks during various shifts.”

“A discontinued medication (Earwax Removal drops) was not properly destroyed according to Department of Environmental Protection and Federal and State regulations. The medication remained in the nursing office by the medication cart rather than being safely disposed of.”

“A staff member altered a resident's check, forged the resident's guardian's name, and cashed the check for personal gain. This constitutes financial exploitation and abuse of a resident.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required for direct care staff qualifications.”

“Direct care staff person B did not receive required annual training topics including medication self-administration training, instruction on meeting resident needs, care for residents with dementia and cognitive impairments, infection control and hygiene principles, safe management techniques, and care for residents with mental illness or intellectual disability during training year 2023.”

“Staff person B did not receive training in emergency preparedness procedures and recognition and response to crises and emergency situations during training year January 2023 to December 2023. Staff person C did not receive training in fire safety or falls and accident prevention during the same training year.”

“Staff person engaged in confrontational communication with a resident who used profanity, asking the resident if they would speak to family members that way, rather than responding with dignity and respect.”

“Door leading to kitchenette in memory care unit was not in good repair; lock did not function properly (occasionally jamming) and a screw was missing.”

“A prescribed as-needed medication was not available in the home at the time it was needed (11:09 AM on 9/8/23), violating safe storage and distribution procedures.”

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

“The home failed to report a reportable incident to the Department within 24 hours as required. An incident reported by Resident #1 to Staff Member A on 7/6/23 was not reported to the Department until 7/10/23, a 4-day delay. This was a repeated violation.”

“The home failed to provide a status report to the complainant within 2 business days after submission of a written complaint regarding resident room placement. The home did not respond to the concern until a delayed date.”

“The home failed to provide a written decision within 7 days after submission of a written complaint regarding resident room placement or removal. The written response provided no specific details regarding the plan of action for the affected resident.”

“Resident #1 was admitted to the Secured Dementia Care Unit without a medical evaluation completed within 60 days prior to admission as required by regulation.”

“Abuse was substantiated. A resident was subject to inappropriate conduct. The facility failed to ensure proper supervision and staff training on residents' rights, mandatory abuse reporting, and abuse prevention.”

“Bathroom cabinets in resident apartments #119 and #121 containing personal hygiene items labeled as poisonous were unlocked, unattended, and accessible to residents. Not all residents had been assessed as capable of safely recognizing and using poisonous materials.”

“Resident #3's preadmission screening form does not include documentation of the resident's ability to safely use and avoid poisonous materials, as required within 30 days prior to admission.”