Bellingham at West Chester.

“A resident-home contract was not signed by the resident as required. The contract must be signed by the administrator or designee, the resident, and the payer.”

“A resident record did not contain a statement signed by the resident acknowledging receipt of resident rights and complaint procedures information.”

“During multiple shifts with 56 residents present, no staff person trained in first aid and certified in obstructed airway techniques and CPR was present in the home. At least one staff person for every 50 residents with these certifications must be present at all times.”

“A staff person completed CPR training with National CPR Foundation, which is not certified as a trainer by a hospital or other recognized health care organization. Training must be provided by a certified trainer from a recognized health care organization.”

“A resident's bedside mobility device procedures do not include periodic assessment for proper installation and maintenance and verification that the device remains appropriate to the resident's needs.”

“A resident's bedside mobility device was uncovered on both sides of the bed with two openings (27.5 inches x 4 inches and 19 inches x 4 inches) creating hazards. Equipment used by residents must be clean, in good repair, and free of hazards.”

“Ceiling tiles in multiple bedrooms and bathrooms were water stained, indicating surfaces that are not clean, in good repair, and free of hazards.”

“The ramp leading to one of the main entrances in the personal care unit lacks a well-secured handrail, with four poles missing or broken.”

“The medication room in the memory care unit where resident information is kept was unlocked, unattended, and accessible to all, violating confidentiality requirements for resident records.”

“Scent Sational odor eliminator with a poison control warning label was unlocked, unattended, and accessible to residents in the memory care unit, where not all residents have been assessed as capable of safely handling poisonous materials.”

“A full, uncovered, unattended trash can was found in the main kitchen, failing to prevent insect and rodent penetration.”

“Bathrooms in the personal care and memory care units lack either an operable outside window or functioning exhaust fan for ventilation.”

“Room A114 lacks a source of light that can be turned on or off at bedside, failing to meet bedroom lighting requirements.”

“The facility's current license, a copy of the current licensing inspection summary, and a copy of 55 Pa Code Chapter 2600 were not posted in a conspicuous and public place in the home.”

“Upon request for immediate access to documents on July 22, 2024, the facility did not provide timely access to reportable incidents, staff training plans, quality management meeting minutes, agency staff lists, fire logs, resident medication records, and CPR certification lists. Documents were provided hours later or via email on July 23, 2024.”

“Violation related to 55 Pa Code § 2600.65f with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.65g with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.107d with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.132a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.185a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.190a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.236 with Class III severity. Fine of $120 per day assessed if not corrected.”

“The Department refused to renew certificate of compliance and issued a FIRST PROVISIONAL license based on violations found during inspection.”

“The Department refused to renew certificate of compliance and issued a FIRST PROVISIONAL license based on violations found during inspection.”

“Violation related to 55 Pa Code § 2600.185a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.190a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.236 with Class III severity. Fine of $120 per day assessed if not corrected.”

“The facility's current license, a copy of the current licensing inspection summary, and a copy of 55 Pa Code Chapter 2600 were not posted in a conspicuous and public place in the home.”

“Upon request for immediate access to documents on July 22, 2024, the facility did not provide timely access to reportable incidents, staff training plans, quality management meeting minutes, agency staff lists, fire logs, resident medication records, and CPR certification lists. Documents were provided hours later or via email on July 23, 2024.”

“Violation related to 55 Pa Code § 2600.65f with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.65g with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.107d with Class III severity. Fine of $120 per day assessed if not corrected.”

“Violation related to 55 Pa Code § 2600.132a with Class II severity. Fine of $200 per day assessed if not corrected.”

“Multiple residents' diabetic readings were not accurately documented on Medication Administration Records. Residents' glucose meters were not calibrated to correct times, and actual readings did not match documented values.”

“Two residents' support plans did not document necessary vision and hearing care services. One resident's vision needs (glasses use) were not documented, and another resident's total hearing impairment was not addressed in the support plan.”

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

“Staff person A was found sleeping at 4:50 AM while on duty in the memory care unit for approximately 15 minutes when 23 residents were present in the home.”

“A brown smear was identified on the banister located in the memory care unit on 11/13/23 at 11:08 AM, indicating unsanitary conditions.”

“The rugs in the memory care unit were spotted, stained, torn, and frayed where the carpet meets the wood/wood-colored flooring, creating surfaces that were not clean or free of hazards.”

“Medical evaluations for three residents were missing the height component on the required form. This is a repeated violation from 3/28/23.”

“Medication administration records (MAR) were missing staff initials for multiple medication administrations and treatments, and diagnoses/purposes were not documented for several medications. This is a repeated violation from 3/28/23.”

“The home did not have a current weekly activity calendar posted in a public and conspicuous place; only a black easel with a single day activity schedule of unknown date was present.”

“Colgate toothpaste and Medline mouthwash with poison control warning labels were unlocked, unattended, and accessible in a resident bathroom. Not all residents had been assessed as capable of safely using or avoiding poisonous materials.”

“Emergency telephone numbers, including nearest hospital and fire department, were not posted on or by the telephone in a resident room.”

“Resident bed enabler was more than 10 inches wide and 4 inches high and was not covered, creating a hazard.”

“A resident's prescribed as-needed medication was not available in the home on the inspection date.”

“Multiple residents' medication administration records lacked required information: purpose/diagnosis for medications, discontinued medications still listed, and missing documentation spaces for dosing times. This is a repeat violation from 03/28/2023.”

“Controlled substance sign-out sheets had discrepancies with medication administration records: multiple sign-outs with missing staff initials, discrepancies between sign-out dates and MAR documentation, and staff initials not entered until after being pointed out by the licensing representative.”

“Resident #2 was discharged but the home did not issue the refund check within the required 30 days. This was a repeat violation from 06/30/2022.”

“The resident-home contract for resident #1 was not signed by the resident and by the administrator. This was a repeat violation from 06/30/2022.”

“Resident #1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. This was a repeat violation from 06/30/2022.”

“The home does not have direct care staff person A's high school diploma on file. This was a repeat violation from 06/30/2022.”

“The home had no director of nursing (last director left on 05/04/2023) and only one medication technician per shift passing medications to both the PC and MC floors. Approximately 19 medication errors were reported to the Department in May, June, and July 2023 due to transcribing errors, pharmacy issues, and insufficient staffing. This was a repeat violation from 06/30/2022.”

“Direct care staff person A and B received only 4 hours and 23 minutes of annual training in training year 2022, falling short of the required 12 hours minimum.”

“Direct care staff person A and B did not receive training in required topics during training year 2022, specifically including medication self-administration training.”