Orion Personal Care.

“Resident annual medical evaluations did not include required information: one evaluation lacked resident weight and immunization status documentation (areas left blank); two evaluations failed to indicate dementia as a diagnosis or note that the resident required secured dementia care.”

“Direct care staff person A administered a prescribed medication after 8:00 a.m. instead of the prescribed 7:00 a.m. time and electronically altered the resident's medication administration records for July, August, and September 2025 to falsely reflect 7:00 a.m. administration.”

“Direct care staff person A failed to administer a prescribed Levothyroxine tablet to a resident at the prescribed 7:00 a.m. time or within one hour prior or after the prescribed time on multiple dates.”

“Two resident annual assessments failed to include the residents' diagnosed dementia with behavioral disturbance that was documented in their medical evaluations.”

“Three residents' support plans lacked resident signatures or documentation indicating whether the resident was unwilling, unable, declined to participate, or refused to sign.”

“Two residents were assessed for the need for Secure Dementia Care Unit (SDCU) placement on initial dates but were not reassessed annually for continued need for SDCU as required.”

“Four instances of resident-to-resident abuse were not reported to the Department within 24 hours as required: resident biting another resident on the right hand, resident grabbing and pulling another resident's shirt and sweater over their head, resident striking another resident in the left temple (resulting in hospitalization), and resident biting another resident.”

“Four instances of resident-to-resident abuse occurred in the home: resident biting another resident on the right hand, resident grabbing and pulling another resident's shirt and sweater over their head, resident striking another resident in the left temple (resulting in hospitalization), and resident biting another resident.”

“A resident admitted to the secured dementia care unit did not have a required medical evaluation completed by a physician, physician's assistant, or certified registered nurse practitioner within 60 days prior to admission.”

“A resident admitted to the secured dementia care unit did not have a required written cognitive preadmission screening completed within 72 hours prior to admission.”

“A resident admitted to the secured dementia care unit did not have an initial support plan developed, implemented, and documented within 72 hours of admission or within 72 hours prior to admission.”

“A resident's support plan did not identify the resident's physical, medical, social, cognitive, and safety needs.”

“Carbon monoxide detector in the basement had AA batteries dated 4/2/18, which had not been replaced annually as required by the Care Facility Carbon Monoxide Alarm Standards Act.”

“Three resident bathroom door locks were inoperable: the bathroom between rooms #9 and #11, the bathroom between rooms #5 and #6, and the second-floor bathroom between rooms #13 and #15. Privacy could not be ensured during bathing, dressing, changing and medical procedures.”

“A newly hired staff person A did not have a criminal background check completed prior to or at the time of hire, as required by the Older Adult Protective Services Act and 6 Pa. Code Chapter 15.”

“Direct care staff person B did not receive required annual training during 2024 in: instruction on meeting resident needs, care for residents with dementia and cognitive impairments, infection control and hygiene, personal care service needs, and safe management techniques.”

“Staff person B did not receive required annual training in falls and accident prevention during the 2024 training year.”

“Exhaust fans in three bathrooms were covered in dust: the bathroom between rooms #9 and #11, the bathroom between rooms #5 and #6, and the second-floor bathroom between rooms #13 and #15. Sanitary conditions were not maintained.”

“The resident bathroom on the second floor between bedrooms #13 and #15 had no illuminating light, preventing safe movement and evacuation for residents, particularly those with vision impairments.”

“Carbon monoxide detector batteries dated 10/12/21 were not replaced annually as required by the Care Facility Carbon Monoxide Alarm Standards Act. Batteries must be replaced at least once annually or when the unit signals a drained battery.”

“The home served 19 residents requiring 57 gallons of emergency drinking water but had only 10 gallons stored on site. The home must maintain at least a 3-day supply of nonperishable drinking water for residents.”

“Fire extinguishers near bedroom #13 and near the courtyard door lacked inspection tags showing they were inspected by a fire safety expert within the past year, as required by regulations.”

“Fire drill records for drills conducted on 1/2/24 and 2/5/24 did not include the time of the drill, which is a required element of the written fire drill record.”

“Directions for operating the home's magnetic locking mechanisms were not conspicuously posted near the devices at three exit locations: the exit door next to bedroom 13, the exit door in bedroom #14, and the exit door in the first floor TV room.”