The 501 at Mattison Estate.

“A resident in the Secure Care Unit eloped from the facility on 2/4/2026. The resident, who requires supervision and uses a WanderGuard device, was able to exit through a delayed egress door by holding the push bar for 15 seconds despite the WanderGuard system being in place. Staff did not immediately respond to the door alarm due to being occupied with other residents. The resident was found by emergency services with injuries from a fall and was not appropriately dressed for the cold weather conditions outside.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, failing to meet minimum qualification requirements for direct care staff.”

“Staff persons A and B did not receive annual training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during the required training year.”

“Two unlabeled cleaning squirt bottles containing unidentified liquid were observed on an unattended housekeeping cart outside room 309. Poisonous materials must be stored in their original, labeled containers.”

“Fire drill record for 3/28/25 incorrectly documented the number of residents evacuated as 28 when all 91 residents present were actually evacuated.”

“Hot water temperature at multiple resident living units exceeded the 120°F maximum threshold. Unit 104 measured 132.6°F and 125.7°F; Unit 103 measured 126.3°F and 120.7°F; Unit 126 measured 135.1°F and 123.4°F.”

“Resident #1 did not have access to a source of light that can be turned on/off at bedside.”

“An unlabeled and undated pie was found in the main kitchen freezer.”

“Fire drill record for 3/28/25 incorrectly documented the number of residents evacuated as 28 when all 91 residents present were actually evacuated.”

“Resident #1 who self-administers medication did not have a current medication list in their record. Six medications present in the living unit were not listed, and one medication was listed but not present.”

“Resident #2's Tramadol 50 mg had tears in the blister pack in three locations, compromising proper storage conditions.”

“Hot water temperature at multiple resident living units exceeded the 120°F maximum threshold. Unit 104 measured 132.6°F and 125.7°F; Unit 103 measured 126.3°F and 120.7°F; Unit 126 measured 135.1°F and 123.4°F.”

“Resident #1 did not have access to a source of light that can be turned on/off at bedside.”

“An unlabeled and undated pie was found in the main kitchen freezer.”

“Resident #1 who self-administers medication did not have a current medication list in their record. Six medications present in the living unit were not listed, and one medication was listed but not present.”

“Resident #2's Tramadol 50 mg had tears in the blister pack in three locations, compromising proper storage conditions.”

“The residence did not post a copy of Chapter 2800 regulations in a conspicuous and public place in the assisted living residence.”

“The residence's most recent annual fire safety inspection was dated 11/29/2023, with the previous one dated 05/23/2022, failing to meet the annual requirement for fire safety inspections conducted by a fire safety expert.”

“The last fire drill conducted during sleeping hours was on 12/13/2023 at 06:00 AM, with the previous one on 05/31/2023 at 05:30 AM, failing to meet the requirement of a fire drill during sleeping hours once every 6 months.”

“A blister pack of Mirtazapine 7.5 mg prescribed for resident #1 remained in the medication cart on 06/05/2024 despite being discontinued on 06/02/2024, violating the requirement that only current medications may be kept in the residence.”

“Two residents had pharmacy labels that did not match prescriber orders: resident #2's Lorazepam Intensol was labeled "every 6 hours" instead of "every 6 hours as needed (PRN)", and resident #4's Oxycodone HCL was labeled "every 8 hours as needed" while the MAR showed "every 6 hours as needed".”

“Resident #1's backup glucometer (Accuchek) was not calibrated to the correct date and time and did not display the date. Additionally, the Freestyle libre history log showed no readings for morning and lunch on 06/04/2024 while the MAR recorded values of 201 and 203 respectively, indicating improper storage, security, and use procedures for medical equipment.”

“Medication administration records did not include the initials of staff persons at the time medications were administered: resident #4's Tramadol administration on 05/31/2024 at 06:30 AM was not initialed, and resident #5's Oxycodone administrations on multiple dates (05/09, 10, 14, 25, 26/2024) were not properly documented with staff initials.”