Cambridge Village Personal Care Home.

“Staff person A's Pennsylvania State Police Criminal Background Check was dated more than 1 year prior to the staff person's date of hire. Staff person B was hired but the Pennsylvania State Police Criminal Background Check was not completed until after the hire date.”

“The door to the Secure Dementia Care nurse's station did not lock.”

“Blood glucose readings recorded on resident #1's glucometer did not match the readings documented in the medication administration record on multiple dates in August 2025 (8/15, 8/16, 8/22, 8/23, 8/26), indicating discrepancies in medication documentation and safe storage procedures.”

“Resident #1 was prescribed blood sugar checks 4 times daily but only received 3 checks on 8/23, 8/24, and 8/26. Additionally, resident #1 received incorrect insulin doses on multiple dates (8/5, 8/6, 8/7, 8/8, 8/16, 8/17, 8/22) not in accordance with the prescribed sliding scale.”

“The text regarding insulin injection requirements is incomplete in the provided document, but this citation appears to reference staff qualifications for administering insulin injections.”

“A resident was prescribed medication to be given every 6 hours as needed, but the medication was not administered when needed because it was not available in the home due to pharmacy and family issues with obtaining and filling the prescription.”

“The support plan for a resident did not address behaviors of agitation and aggression, failing to identify the resident's physical, medical, social, cognitive and safety needs.”

“Resident #1 had an enabler bar attached to bed with an approximate 2-inch gap between the bar and mattress, posing an entrapment hazard. Wheelchairs, walkers, prosthetic devices and other apparatus used by residents must be clean, in good repair and free of hazards.”

“Resident #2 had Omeprazole 20mg in the home's medication cart; however, the medication was discontinued on 2/28/25. Only current prescription, OTC, sample and CAM for individuals living in the home may be kept in the home.”

“Resident #3 was ordered blood glucose checks once daily. However, the resident did not receive a blood glucose check on 3/2/25. The home shall follow the directions of the prescriber.”

“The directions for operating the home's locking mechanism are not conspicuously posted near the door to the Secure Dementia Care Unit (SDCU). A code was posted; however, it indicated several numbers but not which numbers are needed nor in which order to enter in the keypad to exit the SDCU.”

“Direct care staff person A, hired on an unspecified date, provided unsupervised ADL services during a shift without having successfully completed the Department-approved direct care training course or passed the competency test.”

“Inadequate staffing to meet resident needs and ensure timely emergency evacuation. On multiple dates (3/27/23, 3/31/23, 4/4/23, 4/11/23), only 3 staff were present during 11 PM-7 AM shifts with 40-50 residents, including 19 requiring 1-2 person evacuation assistance, 14 in secure dementia unit requiring 24-hour supervision, and 15 using wheelchairs. Staff interviews confirmed inability to evacuate residents timely in an emergency.”

“Fire drill not conducted under typical staffing conditions. The home regularly schedules 3 staff for the 11 PM-7 AM shift, but fire drill records show 6 staff were present during the fire drill conducted on 4/19/23 at 5:45 AM, violating the requirement that drills not be routinely held when additional staff are present.”