Heather Glen Senior Living.

“Direct Care staff persons A and B did not receive training in Safe Management Techniques during training year 2025.”

“At 9:45 a.m. a housekeeping cart was unlocked, unattended, and accessible to residents in the secure dementia Pod B. The cart contained a spray bottle of OxyPlus disinfectant with a manufacturer's label indicating "Harmful if swallowed". The residents of the secure dementia unit have been assessed as not capable of recognizing and using poisons safely.”

“The fire extinguishers in the secure dementia units C, D, and E are stored in locked containers. Not all staff have access to the keys to unlock the fire extinguishers.”

“Resident #1's annual medical evaluation was not completed as required.”

“At 1:40 p.m. the Lantus insulin pen belonging to resident #2 was not dated when the pen was opened for use. According to manufacturer's instructions, the insulin pen should be discarded 28 days after it is opened for use. At 1:41 p.m. a loose Tylenol tablet was found in the 2nd drawer of the secure dementia unit medication cart. This is a repeat violation from 3/5/25.”

“According to the home's narcotic storage policy, staff are required to count narcotics at each shift and sign the daily narcotic count sheet. The narcotic count sheets for March were missing signatures on a daily basis for varying shifts.”

“A resident fell backwards down bus steps while boarding and was not provided timely medical attention. The resident had multiple falls since admission to the secure dementia care unit, but the assessment and support plan was not updated to reflect this history or include a fall prevention plan.”

“The home failed to secure timely medical treatment for a resident who fell at approximately 12:45 p.m. and complained of arm pain around 2 p.m., but 911 was not called until 5:25 p.m. The resident was diagnosed with two fractures at St. Luke's Hospital.”

“The resident's support plan was not revised to include the resident's history of multiple falls since admission to the Secure Dementia Unit, despite the support plan being required to be revised as the resident's condition changes.”

“A resident's record did not include a copy of the resident's death certificate.”

“A staff member took a resident's credit card from their room and used it to purchase items at a local gas station. This constitutes neglect and mistreatment of the resident.”

“A resident fell in the dining room with visible injuries and was hospitalized. The facility did not report the incident to the Department within 24 hours as required; the report was submitted approximately 24 hours late (9:00 a.m. the following day instead of within 24 hours of the 3:00 p.m. incident).”

“The refrigerator in the SDCU pod E kitchenette did not have a thermometer. The refrigerator in SDCU pod B measured 45°F (exceeding the 40°F requirement) and the freezer measured 35°F (exceeding the 0°F requirement).”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, and no waiver was submitted for the diploma requirement.”

“A steam table was left plugged in and turned on in Memory Care pod E, was hot to touch, and was unattended, creating a potential hazard.”

“An open gallon of 2% milk and an open jug of orange juice in the SDCU area of Pod E were not dated when opened.”

“A bag of whip cream that was previously opened was not sealed in the main kitchen. An uncovered plate of scrambled eggs, cooked bacon, and oatmeal was in a refrigerator in the SDCU pod E kitchenette.”

“Menus posted in the main dining room were outdated (2/16/25 through 2/22/25 and 3/2/25 through 3/8/25), and the menus for the upcoming week were not posted. Menus in the SDCU were only posted through 3/8/25.”

“Resident #1 had an expired PRN Acetaminophen 500 mg medication (expired 2-2025) stored in the medication cart.”

“The Medication Administration Record for a resident shows initials indicating eye drops were administered on multiple dates when the medication was not actually available and not given.”

“Multiple medication errors were not reported to the department within 24 hours as required. Specific medications for residents were not administered on multiple dates but were not reported to the department.”

“A PRN medication for a resident was not available in the home at the time needed. The medication was to be applied topically to abdominal folds twice daily as needed for rash.”

“A prescribed medication (Gemtesa tablet) was not available and could not be administered to a resident. The medication was unavailable due to pending insurance coverage approval.”

“A resident did not receive multiple prescribed medications due to unavailability, including eye drops for dry eyes, nasal spray, and various tablets for hypertension and other conditions on multiple specified dates.”

“Medication errors were not immediately reported as required.”

“The facility failed to document additional assessments for a resident whose condition significantly changed. Staff interviews revealed the resident exhibited agitation and verbal aggression when personal space was invaded, but these behaviors and related care needs were not reflected in the resident's Assessment and Support Plan.”

“A resident's family had installed a camera in the resident's room that was recording both audio and video, violating the resident's right to privacy during personal care activities such as bathing, dressing, and changing.”

“Residents #1 and #2 engaged in a verbal altercation in the secure dementia unit, during which resident #2 grabbed resident #1's arms, causing bruising and a skin tear. This constitutes mistreatment/neglect as residents were not adequately supervised to prevent physical harm.”

“The support plan for resident #2 was not updated to reflect the resident's aggressive behaviors towards other residents, as required annually and when resident condition changes.”

“The home had a census of 94 residents, requiring 2 staff trained in First Aid and CPR to be present at all times. On 3/15/24, only 1 person trained in First Aid and CPR was present in the building from 11pm to 3am.”

“In the bathroom of resident room B2, there was a brown substance smeared on the toilet seat that appeared to be feces.”

“There was no light accessible at bedside in resident room B2 or resident room 237.”

“There was a thick layer of lint in the lint trap of the dryer in the laundry room located near resident room E1.”

“The exit door near resident room 110 was locked and needed a code to be unlocked, preventing immediate egress.”

“The home was given an evacuation time of 15 minutes by the fire safety expert. The home conducted a fire drill on 4/14/23 with a recorded time of 15 minutes and 26 seconds, which exceeded the evacuation time allotted.”

“Resident #1's glucometer was not calibrated to the correct date (reflected 3/23/24 on 3/22/24). Resident #6's PRN prescription for Gentllax Suppositories was not in the medication cart at the time of inspection.”

“A resident in the secured dementia care unit who required supervision and 2-hour safety checks eloped from the facility and checked into a nearby hotel approximately 3 miles away. Staff failed to complete the required 2-hour safety checks, allowing the resident to leave undetected and remain missing for an extended period.”