Bristol House Memory Care.

“The home's license inspection summary was not posted in a conspicuous and public place in the home.”

“The home does not have resident council meeting minutes or quality management meeting minutes as required. The quality management plan does not adequately address periodic review and evaluation of reportable incidents, complaints, staff training, licensing violations, and resident councils.”

“The home does not have criminal background checks on file for Serenity hospice staff members who provide services to residents. All third-party vendors providing services to residents must supply background checks for their staff members.”

“Staff person A, the administrator, did not maintain a complete staff list including agency staff, substitute personnel, and volunteers with their names, addresses, and telephone numbers.”

“Direct care staff person B received only 2 hours of annual training in training year 2024, failing to meet the minimum 12 hours of annual training required relating to job duties.”

“Direct care staff person B did not receive required training topics during training year 2024 including: medication self-administration training, instruction on meeting resident needs, personal care service needs, safe management techniques, and care for residents with mental illness or intellectual disability.”

“Staff could not provide immediate access to records upon request by Department agent. Records were not provided until the next day at 5:26 pm.”

“Two residents' contracts were not signed by the residents and there was no indication the residents were given the opportunity to sign.”

“Staff person C hired in 2024 did not have an acknowledgement of residing in PA for over 2 years, had only a work authorization permit issued in 2023, and had no FBI clearance completed. This was a repeated violation from prior inspections.”

“Staff person D was hired in 2024 but background check was not completed until 7/31/2024, indicating the check was not completed before employment.”

“The administrator did not have required qualifications including a registered nurse license, licensed practical nurse license with one year experience, associate's degree, 60 or more college credits, or nursing home administrator license.”

“Direct care staff person D did not receive training in the following required topics during training year 2023: medication self-administration training; instruction on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan; and care for residents with dementia and cognitive impairments.”

“The resident-home contract for resident #1 was not signed by the resident. The resident-home contract for resident #2 was not signed by the resident.”

“Staff A, hired on a specified date, has not held permanent residency in Pennsylvania for the two consecutive years prior to beginning employment; however, the home failed to run an FBI check. This is a repeat violation from 12/27/2023.”

“The staff list provided on 10/16/2024 did not include housekeeping staff A or maintenance staff C who had been hired, and the administrator does not update the staff list when hiring new employees.”

“On 10/14/2024 from 11PM to 7AM, on 10/13/24 from 7AM to 3PM, and on 10/11/24 from 11PM to 7AM, with 32 residents present in the home, there was no staff person present who was certified in first aid/CPR.”

“Direct care staff person D received only 5.75 hours of annual training in training year 2023, failing to meet the required 12 hours of annual training relating to their job duties.”

“Staff person D was hired on an unspecified date, and a background check was not completed until a later unspecified date, indicating hiring occurred prior to completion of required background checks.”

“On the inspection date, the home was serving 35 residents. Staff person E, the administrator, does not have a license from the Pennsylvania Department of State as a registered nurse, licensed practical nurse with one year of work experience, an associate's degree, 60 or more credits from an accredited college or university, or a nursing home administrator license on file.”

“Staff could not provide immediate access to records requested by a Department agent. On one occasion, access was delayed approximately 1 hour 20 minutes until another staff member arrived. On another occasion, requested documentation was not provided until 5:26 pm.”

“Two resident-home contracts were not signed by the residents, with no indication that the residents were given the opportunity to sign the contracts.”

“Staff person C, hired on an unspecified date, did not have an acknowledgement of Pennsylvania residency for over 2 years and no FBI clearance was completed. The staff member had a work authorization permit issued but lacked required criminal history checks.”

“Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. This is a repeat violation.”

“Staff person E, the administrator, maintains a list of staff persons that does not include all staff members employed at the facility.”

“The home's record of direct care staff training for staff member D does not include the date, source, length of each course, and copies of certificates received as required.”

“The resident or the resident's designated person was not involved in the development of the support plan. Facility policy requires family members to be involved in each care plan, and this involvement did not occur for at least one support plan.”

“Residents' task sheets containing care needs, skin checks, and shower schedules were left unlocked, unattended, and accessible to both residents and visitors on a counter in the common area, violating record confidentiality requirements.”

“Multiple poisonous materials including toothpaste and hair spray were unlocked, unattended, and accessible to residents #1, #2, and #3, who have not been assessed as capable of recognizing and using poisons safely. This is a repeat violation from 2/22/24, 12/27/23, 5/15/23, and 03/21/23.”

“An overflowing, uncovered, and unattended trash can filled with breakfast waste was found in the Gold Finch kitchen. This is a repeat violation from 2/22/24 and 12/27/23.”

“Resident #4 was admitted to the Secure Dementia Care Unit but the resident's medical evaluation was not reviewed for the necessity of a secure dementia unit. This is a repeat violation from 11/6/2023.”

“Residents #1, #2, and #4 were admitted to the Secure Dementia Care Unit without proper written cognitive preadmission screening completed within 72 hours prior to admission. For resident #2, the completion date was not recorded.”

“Resident #4 was admitted to the Secure Dementia Care Unit but the resident's initial support plan was not completed within 72 hours prior to or following admission.”

“Medication labels identifying residents were located outside the medication cart, unsecured and accessible to passersby, violating resident record confidentiality and HIPAA protections.”

“Staff person A, hired on an unspecified date, was not a Pennsylvania resident for two years at time of hire and did not have FBI clearance. This is a repeated violation from 3/21/2023 and 5/15/2023.”

“On 12/25, 12/26, and 12/27/2023, with 47 residents requiring mobility assistance, a minimum of 94 hours of direct care staffing was required but only 82.5 hours was provided.”

“On 12/25, 12/26, and 12/27/2023, although 94 hours of direct care was required, only 60 hours (63.8%) were provided during waking hours, falling short of the required 75% minimum.”

“Medication labels identifying residents were located outside the medication cart, unsecured and accessible to passersby, violating resident record confidentiality and HIPAA protections.”

“Staff person A, hired on an unspecified date, was not a Pennsylvania resident for two years at time of hire and did not have FBI clearance. This is a repeated violation from 3/21/2023 and 5/15/2023.”

“On 12/25, 12/26, and 12/27/2023, with 47 residents requiring mobility assistance, a minimum of 94 hours of direct care staffing was required but only 82.5 hours was provided.”

“On 12/25, 12/26, and 12/27/2023, although 94 hours of direct care was required, only 60 hours (63.8%) were provided during waking hours, falling short of the required 75% minimum.”

“Medication labels identifying residents were located outside the medication cart, unsecured and accessible to passersby, violating resident record confidentiality and HIPAA protections.”

“Staff person A, hired on an unspecified date, was not a Pennsylvania resident for two years at time of hire and did not have FBI clearance. This is a repeated violation from 3/21/2023 and 5/15/2023.”

“On 12/25, 12/26, and 12/27/2023, with 47 residents requiring mobility assistance, a minimum of 94 hours of direct care staffing was required but only 82.5 hours was provided.”

“On 12/25, 12/26, and 12/27/2023, although 94 hours of direct care was required, only 60 hours (63.8%) were provided during waking hours, falling short of the required 75% minimum.”

“Resident #2 was admitted to the Secured Dementia Care Unit but the medical evaluation documenting the diagnosis of dementia and need for secured dementia care was not completed within 60 days prior to admission.”

“No toilet paper was provided for 2 toilets in the main hallway bathroom during the inspection on 11/06/2023 at approximately 12:00 PM.”

“Medical evaluations for three residents were incomplete: Resident #1's evaluation did not document the ability to self-administer medications; Resident #2's evaluation lacked special health or dietary needs and immunization history; Resident #3's evaluation was not completed for dementia care admission and lacked special health or dietary needs documentation. This was a repeated violation from 3/21/23 and 5/15/23.”