Revelle of Bucks County Senior Living.

“Facility failed to report a resident incident within 24 hours. Resident fell in bathroom on 10/26/2025 at 6:00 am, struck their head, and had fallen again the previous day. After being hospitalized in intensive care with a cervical fracture, the facility did not report the incident to the Department until 10/27/2025 at 1:30 pm.”

“Resident's medical evaluation was performed more than 60 days prior to admission, violating the requirement that medical evaluations must be completed within 60 days before admission or within 15 days after admission.”

“Facility failed to provide timely ADL assistance. A resident requiring assistance with transferring in/out of bed and ambulating used their call bell at 3:25 pm on 10/25/2025 and waited 45 minutes and 10 seconds for a response, despite having reported two falls since the previous day and complaining of pain.”

“Facility failed to provide adequate direct care staffing for residents with mobility needs. On the inspection date, 55 residents included 28 with mobility needs requiring minimum 83 hours of direct care service, but only 77.11 hours were provided.”

“Facility failed to maintain adequate waking hour staffing. Of the required 83 hours of direct care, only 54.11 hours (65 percent) were provided during waking hours, falling short of the 75 percent requirement.”

“Resident requiring complete assistance with personal hygiene due to physical weakness and high fall risk did not receive required assistance on the date of inspection at approximately 6:40 AM.”

“Resident-residence contract was not signed by the resident. Contract for resident unable to be reviewed and signed as resident was hospitalized and subsequently discharged from the residence.”

“Staff member failed to provide required stand-by assistance to resident with documented diagnosis and physical weakness during bathroom transfer and hygiene assistance. Staff member was forceful in instructing resident to stand without physical support, raised their voice, escalated interactions, expressed frustration about assisting the resident, and left resident unattended multiple times despite explicit care plan requirements.”

“Direct care staff member's training record does not include training history since hire date and lacks details such as date, source, content, length of courses, and copies of certificates.”

“Additional written assessment was not completed for resident admitted to memory care unit when the resident's condition significantly changed prior to annual assessment.”

“A bedside mobility device on Resident #1's bed was not securely attached to the bedframe and could slide up to 7 inches away, creating entrapment zones and posing a hazard to the resident. This was a repeat violation.”

“Dried feces were found on the toilet seat of Resident #1's bathroom at 9:58 A.M., indicating unsanitary conditions.”

“A bag of cookie dough and a bag of fried steak in the walk-in freezer were opened and unsealed, violating food storage requirements. This was a repeat violation.”

“Two unlabeled laundry hampers belonging to residents were placed in the commercial laundry room without identifying names or room numbers, creating a risk of lost or misplaced clothing.”

“Resident #2's most recent medical evaluation was completed late in 2024, with the previous evaluation completed in 2023, failing to meet the annual evaluation requirement. This was a repeat violation.”

“Resident #3, prescribed blood sugar readings 4 times daily at specified times, had a blood sugar reading of 173 recorded on the medication administration record at 4:16 P.M. on 1/8/25, indicating potential issues with medication administration procedures and documentation.”

“Resident was admitted but the facility could not provide initial medical evaluation or documentation that an evaluation was completed within the required timeframe.”

“Medication order specified administration on Wednesday, Friday, Saturday at 08:00 PM and Sunday, Monday, Tuesday, Thursday at 08:00 PM, but was administered on Mondays, Wednesdays, and Fridays, resulting in missed doses on Saturdays and double doses on Mondays for at least 2.5 months (September-December 2024).”

“The residence does not have a system in place to identify and document medication errors and patterns of errors. A medication error involving incorrect scheduling resulted in missed doses and double doses for over 2.5 months, but neither administrative nor supervisory staff could describe a system for identifying such errors.”

“An unlabeled, undated container of turkey was found in the kitchen refrigerator, violating the requirement that outdated or spoiled food and dented cans may not be used.”

“A direct care staff member failed to respond to multiple calls and voicemail messages from a Department agent requesting clarification on a resident's progress note entry. The staff member did not comply with the Department's request for communication despite the administrator's instruction to do so.”

“A direct care staff member on their first day of work did not receive orientation on fire safety and emergency preparedness, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and telephone use for emergency services. This is a repeat violation from 04/15/2024.”

“A direct care staff member did not complete required 40-hour orientation training on resident rights, emergency medical plans, mandatory reporting of abuse and neglect, reportable incidents and conditions, safe management techniques, and core competency training in person-centered care, communication skills, and nutritional support.”

“A direct care staff member provided unsupervised assisted living services from August 2023 without completing the Department-approved direct care training course and passing the competency test.”

“Resident admitted to special care unit is missing the determination in the written cognitive preadmission screening that the resident's needs can be met by the residence.”

“Medical evaluation for resident dated 09/21/2023 does not include immunizations and tuberculosis testing documentation. This area of the form is blank.”

“Resident was prescribed medication every 6 hours as needed for agitation/anxiety and this medication was administered when the resident refused to stay in bed and tried to get out of bed on multiple occasions, constituting use of a chemical restraint to control behavior.”

“The residence's May 2024 activity calendar does not have any activities planned for residents in the Secured Dementia Care Unit (Generations). The calendar includes trips only available to other residents, and Wednesday activities show only "10:00 Memory Care" with no details of activities planned.”

“Resident assessment/support plan was not signed by the assessor, the resident, or the family/designee.”

“Support plan for resident in special care unit was not updated to reflect significant changes in condition after return from skilled rehab requiring full assistance and 2-person transfers, and initiation of hospice care. The ASP dated was a copy of a previous ASP without reflecting these changes.”

“Resident did not receive required assistance with transfers in and out of bed as indicated in their assessment and support plan dated 3/5/22.”

“Staff Member A instructed a resident not to ring the call bell, then left the residence at approximately 5:00 AM without administrative knowledge, leaving only one staff member to care for 15 residents, 7 of whom have mobility needs. The resident was found sleeping in a wheelchair and unable to return to bed independently.”

“A resident's call bell was not working properly and did not alert staff when pressed. Testing revealed a pendant was not sending notifications to staff pagers, and a box of pendants was identified as defective.”

“Staff Member A did not properly count narcotic medications at the end of the 11 PM to 7 AM shift as required; Staff Member A was not present in the building when the incoming shift arrived, despite another staff member signing off that a count was completed together.”

“Seven residents did not receive their prescribed medication because only one medication staff member was working overnight for the entire building, and the oncoming shift failed to address this gap.”

“Seven residents prescribed daily medication did not receive their medication on the date prescribed.”

“A resident's initial assessment and support plan was not signed by the assessor and the resident as required.”

“A resident's initial assessment and support plan was not signed by the resident, and the residence did not document a notation regarding the resident's ability or refusal to sign.”

“A resident reported that cash was missing from their top dresser drawer. The resident had stored approximately $300 in a small box labeled 'CASINO CARDS AND EXTRAS' in the top left-hand corner of their dresser, along with casino cards. The money was found to be missing, and the resident's room was searched with no money found or displaced.”

“Staff member A failed to wash hands before administering eye drops to resident 1 at 12:00 pm on 6/14/23, and failed to wash hands before checking blood sugar of resident 2 at 12:10 pm on 6/14/23.”

“Resident #3 and a designated person participated in the development of the preliminary support plan; however, neither resident #3 nor the designated person signed and dated the preliminary support plan.”

“Resident #3's significant change assessment plan did not include the date of completion.”

“Resident #3's record does not include a photograph of the resident that is no more than 2 years old, as required by 55 Pa Code § 2800.252(3).”