Chestnut Knoll.

“The home failed to report to the Department within 24 hours when a resident was transported to the hospital for worsening wounds under their abdomen.”

“Approximately 1 inch of snow at the memory care exit door by a resident room prevented the door from fully opening, creating a potential safety hazard.”

“The facility failed to report a resident's unwitnessed fall and hospital visit for potential injury to the Department within 24 hours. The resident was taken to Pottstown Hospital at 4:25 a.m. but the incident was not reported to the department until 12:00 p.m. the same day.”

“Staff person A engaged in abusive and neglectful care practices including causing bruising during rushed care delivery, arguing with a resident, being frequently bossy during care, and disrespectfully checking a resident's brief without asking permission, causing the resident to fear returning to the home.”

“A laptop containing resident records was left unlocked, unattended, and accessible to residents in the Memory Care Resident Living Room/TV Common-Area at 10:10 a.m.”

“A large white blanket was observed behind the commercial dryer directly underneath the external duct, creating a fire hazard by storing combustible materials near a heat source.”

“A resident with continuous blood glucose monitoring device orders could not have blood glucose history accessed by home staff as only the physician could access records. Additionally, a resident's PRN medication was not available in the medication cart, having expired on 7/31/2025 without refill requested.”

“A bottle of hand sanitizer with a manufacturer's label was found accessible to residents in violation of requirements that poisonous materials be kept locked and inaccessible.”

“Batteries for carbon monoxide monitors located outside the Bistro Kitchenette area and outside the personal care kitchen were not labeled with the date of installation as required by the Care Facility Carbon Monoxide Alarms Standards Act.”

“A laptop located on a medication cart in the main floor hallway near the wellness office was unlocked, unattended, and accessible to residents' records, violating record confidentiality requirements.”

“Staff Person A who was hired did not have a Pennsylvania State Police Criminal Background Check requested prior to the start date, in violation of criminal history check requirements under the Older Adult Protective Services Act.”

“Staff Person B hired did not receive training on instruction regarding meeting residents' needs as described in the preadmission screening form, assessment tool, medical evaluation and support plan during the 2024 training year.”

“Staff Persons B, C, D, E, F, and G hired did not receive fire safety training completed by a fire safety expert or by a staff person trained by a fire safety expert during the 2024 training year.”

“The home failed to verify the correct medication strength with the medication administration record before administering medication to a resident. The resident was given an incorrect dose instead of the prescribed strength.”

“A discontinued medication was discovered in the home's medication cart. The resident had been discontinued on this medication, but it remained in the medication cart.”

“The home failed to follow prescriber's orders in multiple instances: a resident was administered an incorrect medication strength instead of the prescribed 125mg dose; another resident prescribed to receive medication every other day was administered on incorrect dates; and a third resident prescribed medication every other day was administered 3 times weekly instead.”

“Two residents participated in the development of their support plans but did not sign the support plan documents as required.”

“The resident's support plan was not updated in a timely manner to address the resident's fall history and safety planning needs.”

“A resident was found lying on top of another resident in a resident room with both residents' clothing partially removed. One resident stated the other had asked them to do it, while the other resident denied this claim. The incident resulted in both residents being assessed, hospitalized for evaluation, and interviewed by police.”

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

“Resident #2 had discontinued medications (Simvastatin and two blister packs of Warfarin 2.5mg) in the med cart. Resident #4's discontinued Levothyroxine 137mcg was also in the med cart. Only current prescriptions should be maintained in the facility.”

“Resident #3's Humolog 100u/ml Kwikpen opened on 6/29/24 had expired on 7/26/24, and Haloperidol Con 2mg/ml had expired on 7/29/24. Both expired medications were in the med cart at time of inspection.”

“Resident #2's Warfarin 3mg blister pack was labeled with directions to take ½ tablet at bedtime, but the current order specified 1 tab every evening. Resident #5's GNP Glucose Chew Grape label incorrectly stated to chew 1 tab 30 minutes prior to physical activity instead of the prescribed 1 tab daily.”

“Resident #3's Geritussin PRN, Resident #4's acetaminophen 325mg PRN, and Resident #4's GNP eye drop PRN were not available in the med cart at time of inspection despite active orders for these medications.”

“Staff member A struck a resident on the right arm in response to the resident becoming physical. A red mark was found on the resident's arm in the area where the strike occurred. The incident was witnessed by another staff member.”

“Resident #2's Resident Assessment and Support Plan (RASP) did not indicate specific dietary needs; it only referred to MD orders without specifying the actual prescribed diet.”

“Two medication administration errors where prescriber's orders were not followed: Resident #3 was given Lisinopril 2.5mg on 8/15/23 at 9:08am when systolic blood pressure was 112/67 (order stated HOLD for SBP less than 120). Resident #4 was given metoprolol succinate 25mg on 8/12/23 when heart rate was 58 (order stated hold for HR less than 70). This is a repeat violation from 5/24/22.”

“Resident #1 was observed abusing Resident #2 while Resident #2 was holding Resident #1's hand. This is a repeat violation from 4/12/23. Resident #1 was issued a 30-day notice of discharge and transferred to another facility.”

“Hot water temperatures in resident-accessible areas exceeded the 120°F limit: Room 418 measured 122.3°F, common restroom outside Room 418 measured 123.3°F, and Room 318 measured 122.4°F.”

“Resident #3's Ester-C medication label did not include the prescribed dosage (MAR states 500mg). Resident #3's Probiotic label did not have the dosage listed (MAR states 250mg twice a day). Both are supplemental medications from an outside pharmacy.”

“Resident #5's glucometer was not calibrated to the correct time, which is a failure to implement proper storage and maintenance procedures for medical equipment.”

“Resident #3's Medication Administration Record (MAR) did not indicate a dosage for Daily-Vite, a supplemental medication from an outside pharmacy.”