Belle Reve Senior Living Center.

“A resident with a known history of sexually abusing other residents was found in another resident's bedroom with that resident's shirt pulled up while touching their breasts. This is a repeat violation occurring on 7/10/25 and 2/25/25.”

“All memory care resident bedrooms are being locked when residents are not in them, requiring residents to find staff to open their doors to gain access. This violates the requirement that residents have access to their bedrooms at all times.”

“Staff witnessed one resident place their hand inside the pants of another resident and touch their genital area. Both residents reside in the secured dementia care unit and are unable to give consent, constituting potential abuse/neglect.”

“A resident's most recent medical evaluation was not completed within the required annual timeframe.”

“The double glass doors leading to the outdoor balcony on the 3rd floor of the secure dementia care unit did not have a sign stating 'THIS IS NOT AN EXIT,' which is required to ensure unobstructed egress routes are properly marked.”

“A resident's debit card was stolen and funds were taken from the account. The facility failed to provide a system for safeguarding the resident's valuables.”

“A resident in the secured dementia unit was found in another resident's room engaged in inappropriate sexual contact. Both residents are unable to consent. The resident was redirected by staff, and both residents were assessed with no injuries or distress noted.”

“Fire extinguisher #22 in the East 2 wing did not have a tag indicating annual inspection by a fire safety expert.”

“Staff person A did not receive annual fire safety training by a fire safety expert or staff trained by a fire safety expert during the 2024 training year.”

“Resident #1's glucometer displayed a reading of 343 on 4/20/25 at 6:12 P.M., but the Medication Administration Record had no documentation of a reading for the 4:00 P.M. scheduled reading.”

“Multiple instances of insulin administration not matching prescriber's orders for Residents #1 and #2: Resident #1 received 10 units instead of 4 units of Humulin N on 4/25/25 when blood glucose was 181; Resident #2 received incorrect doses of Humalog multiple times (15 units and 18 units before meals instead of 4 units; 25 units instead of 16 units on 4/14/25; 4 units instead of 18 units on 4/22/25 and 4/25/25).”

“Resident #3's assessment documented the resident uses an enabler bar but did not indicate risks associated with the device or the resident's ability to use the device safely for its intended purpose.”

“The south side emergency exit door was blocked by a patio chair, obstructing the egress route from the building.”

“Two residents in the secure dementia care unit were found in a sexually inappropriate situation. Due to cognitive decline, neither resident could consent to sexual contact. Staff immediately responded, redirected residents, assessed for injuries, and notified physicians and families.”

“A reportable incident that occurred at 10:15am was not reported until 3:10pm, failing to meet the 24-hour reporting requirement to the Department's regional office or complaint hotline.”

“A resident requiring extensive supervision eloped from the facility on 09/06/2024 and walked to town where local police found them. The resident was without supervision while out of the building, in violation of the requirement to provide assistance with activities of daily living as indicated in the resident's support plan.”

“A resident in the secure dementia unit pushed another resident out of a recliner onto the floor. Staff responded and assessed both residents, finding no injuries, but the incident demonstrated a failure to maintain dignity and respect.”

“A staff person mistakenly used a glucometer intended for one resident to test the blood sugar of another resident, violating sanitary conditions requirements.”

“A medication technician staff person who administers medications had only completed modified medication technician training on 2/18/23 and did not complete the full medication administration training required by regulations.”

“A resident with an order for one daily application of medication was administered the medication twice on 6/24/24 (at 9:43am and 9:35pm), violating the prescriber's orders. This was a repeat violation from 2/27/24.”

“Resident #6 was found with a white bottle of tablets on a side table in their room. The resident does not have an order for these tablets on their medical evaluation or medication administration record, and the resident is not assessed as able to self-administer medications.”

“Multiple medication administration errors were found: Resident #1 and #5 had orders for blood sugar checks multiple times per day with insulin per sliding scale, but no documentation of readings or administration was found on the MAR. Resident #4's prescription called for injection twice daily, but was administered a different medication for the evening dosage. Resident #3's prescription for insulin stated to inject per day before meals but hold if reading is below a certain level; however, the resident was administered insulin on multiple dates without appropriate documentation of adherence to hold parameters. Resident #2 was administered insulin without appropriate documentation relative to sliding scale thresholds.”

“The home failed to complete the pre-admission screening form for Resident #1 by not checking the YES box to indicate that the home could meet the resident's needs. This was a repeat violation from 2/27/2024.”

“Staff denied access to a resident's electronic record to a representative of the Long-Term Care Ombudsman Program who was accompanying a family member requesting to review the resident's records.”

“There is no documentation to verify that resident #8 was educated on residents' rights upon admission.”

“The records for Staff Person B, hired 2/21, did not contain a Criminal History Check as required by the Older Adult Protective Services Act and 6 Pa. Code Chapter 15.”

“The home did not have a copy of Chapter 2600 (pink book) posted in a conspicuous and public place in the personal care home. This was a repeat violation.”

“The administrator did not provide immediate access to residents' records upon request by Department Representatives. Records requested at approximately 10:45am were not provided until 1:00pm, and Resident Contracts were not included in the files.”

“License Inspection Summaries dated 8/3/23 and 8/23/23 were posted in the lobby of the home with Resident Privacy Coding pages attached, violating resident record confidentiality.”

“Resident #8's contract dated 2/14/23 was not signed by the resident and there was no documentation that the resident was offered to sign the contract.”

“Soiled bed sheet was observed draped over a recliner in a resident's room and a soiled cushion was found on the resident's bathroom sink during a family visit. The items appeared to have been left in the resident's room after care was provided, indicating a failure to maintain sanitary conditions.”

“Resident #1 did not sign their Initial Resident Assessment and Support Plan (RASP). No notation was documented indicating whether the resident or their designated person was unable or chose to refuse to sign the initial support plan.”