Brightview Devon.

“The resident-home contract does not include a fee schedule listing the actual amounts charged for available personal needs services.”

“A resident room had a very strong pungent odor, indicating failure to maintain sanitary conditions.”

“Resident records do not include identifying marks and an inventory of personal property as voluntarily declared upon admission and updated as new items are added.”

“The home submitted an alleged abuse initial incident report but did not submit a final report to the Department regional office immediately following the conclusion of the investigation, which concluded with staff member termination.”

“A staff member yanked bed linens up quickly and forcefully while providing care to a resident, causing the resident to strike their head on a dresser without warning. The staff member was reported to have been impatient and nasty in demeanor during the incident.”

“Fish in the main kitchen walk-in freezer was found opened and unsealed on 01/08/2025 at 11:46 am. Food must be stored in closed or sealed containers.”

“Feces were smeared in the bathroom sink of room 320, creating unsanitary conditions. Immediate action was taken to clean the sink on the same date.”

“Emergency telephone numbers for the nearest hospital and fire department were not posted on or by the telephone in room 320. Required numbers include hospital, police, fire, ambulance, poison control, local emergency management, and personal care home complaint hotline.”

“The Controlled Substance Form for a resident's syringes does not include the quantity of syringes received, violating documentation requirements for controlled substances.”

“Glucometer readings for two residents were not accurately recorded; readings taken at specific times were recorded as different values, indicating a failure to properly implement medication storage and medical equipment use procedures.”

“An uncovered, unwrapped, undated container of ice cream was found stored in the pantry freezer of the memory care unit, violating food protection requirements during storage.”

“A resident prescribed medication for severe anxiety was administered the medication on 06/09/24 to control agitation without documented evidence that other behavioral interventions were attempted first, potentially constituting inappropriate use of medication as a chemical restraint for behavior control.”

“Resident records were not kept confidential. Staff member A was observed cutting medication packages and discarding packaging with resident information in trash. Medication room on 4th floor was left unlocked, unattended, and accessible with medication cart and narcotics box open.”

“Resident reported being hit by staff member E, resulting in a large bleeding skin tear on left forearm. Staff member E pushed the resident's arm after the resident resisted pendant clearing, causing the injury. Staff member E was terminated.”

“Criminal background checks were not on file for Staff Member F and Staff Member G at time of inspection.”

“Staff person H did not receive required first-day fire safety and emergency preparedness orientation, including evacuation procedures, staff duties during emergencies, designated meeting place, smoking safety, fire extinguishers, smoke detectors and fire alarms, and emergency notification procedures.”

“Staff member B was suspended following an allegation of abuse but was brought back to work on an unspecified date without an approved plan of supervision. The Department did not complete its investigation until 07/20/23.”

“Direct care staff person B does not have a U.S. 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 training during 2022 in medication self-administration, instruction on meeting resident needs as described in preadmission screening form/assessment tool/medical evaluation/support plan, and personal care service needs of the resident.”

“Staff person B did not receive required annual training during 2022 in fire safety completed by a fire safety expert or trained staff person, and the Older Adult Protective Services Act.”