Penn Highlands Jefferson Manor P. C..

“Suspected abuse of a resident (resident punched in the face) was not immediately reported to the local Area Agency on Aging as required by the Older Adult Protective Services Act.”

“Suspected abuse incident was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“Multiple residents' medical information including medication orders and pharmacy labels were left unlocked, unattended, and accessible at the nurse's stations in both the main entrance area and the Secure Dementia Care Unit, violating resident record confidentiality requirements.”

“Suspected abuse of a resident (resident punched in the face) was not immediately reported to the local Area Agency on Aging as required by the Older Adult Protective Services Act.”

“Suspected abuse incident was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“Multiple residents' medical information including medication orders and pharmacy labels were left unlocked, unattended, and accessible at the nurse's stations in both the main entrance area and the Secure Dementia Care Unit, violating resident record confidentiality requirements.”

“A resident ceased to breathe on an unspecified date in March 2026, but the home did not report this death to the Department within 24 hours as required. This was a repeat violation with prior citations on 7/8/25, 8/21/25, and 9/11/25.”

“A u-shaped bedside mobility device attached to resident #2's bed was not securely attached to the bed frame and moved greater than 3 inches in all directions. Additionally, the device had a 4-inch by 2-foot open area at the center without a cover, posing a head and neck entrapment risk.”

“Emergency telephone numbers were not posted on or near the landline phone in the first-floor conference room, as required.”

“A couch located across from the second-floor nurses station was in poor repair with multiple areas on the cushions and arms where the covering was missing or removed, exposing the underlying material and creating a hazard.”

“Resident #3 was prescribed Cipro 500mg twice daily for 7 days starting 3/18/26, but the medication remained in the medication cart on 4/1/26 after the prescription had been discontinued, indicating improper removal of discontinued medications.”

“A direct care staff person hired in 2020 who works in the secured dementia care unit completed only 3.5 hours of the required 6 hours of annual dementia care training.”

“A morning bubble pack containing resident #1's prescription information for Nitrofurantoin and a lime green binder containing resident narcotic count information were left unlocked, unattended, and accessible on top of the medication cart near the front entrance of the home, violating resident record confidentiality. This was a repeated violation from 07/08/2025 and other dates.”

“A resident ceased to breathe on an unspecified date in March 2026, but the home did not report this death to the Department within 24 hours as required. This was a repeat violation with prior citations on 7/8/25, 8/21/25, and 9/11/25.”

“A u-shaped bedside mobility device attached to resident #2's bed was not securely attached to the bed frame and moved greater than 3 inches in all directions. Additionally, the device had a 4-inch by 2-foot open area at the center without a cover, posing a head and neck entrapment risk.”

“Emergency telephone numbers were not posted on or near the landline phone in the first-floor conference room, as required.”

“A couch located across from the second-floor nurses station was in poor repair with multiple areas on the cushions and arms where the covering was missing or removed, exposing the underlying material and creating a hazard.”

“Resident #3 was prescribed Cipro 500mg twice daily for 7 days starting 3/18/26, but the medication remained in the medication cart on 4/1/26 after the prescription had been discontinued, indicating improper removal of discontinued medications.”

“A direct care staff person hired in 2020 who works in the secured dementia care unit completed only 3.5 hours of the required 6 hours of annual dementia care training.”

“A morning bubble pack containing resident #1's prescription information for Nitrofurantoin and a lime green binder containing resident narcotic count information were left unlocked, unattended, and accessible on top of the medication cart near the front entrance of the home, violating resident record confidentiality. This was a repeated violation from 07/08/2025 and other dates.”

“Staff person refused to provide requested medication (Milk of Magnesium) and refused to call 911 when resident with Dysphagia diagnosis reported swallowing issues and choking concerns. The allegation was not reported to the local Area Agency on Aging as required.”

“Incident involving medication refusal and 911 call refusal was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“Medication administration records for Resident #1 did not include initials of staff person who administered Mirtazapine, Atorvastatin, Risperidone, and Haloperidol on 9/7/25 at specified times.”

“The home failed to immediately report suspected abuse allegations to the local Area Agency on Aging. On 7/21/25, resident #1 reported inappropriate contact by staff person B, but the home did not report until 7/23/25 at 8:00 a.m. On 8/9/25, staff found resident #2 unsupervised kissing resident #3, but the home did not report until 8/11/25 at 12:00 p.m.”

“The home failed to immediately develop and implement a plan of supervision or suspend staff person B following the allegation of abuse on 7/21/25. Staff person B continued to work unsupervised without an approved plan of supervision from the Department.”

“The home failed to report allegations of abuse to the Department within 24 hours. The 7/21/25 allegation was not reported to the Department at all. The 8/9/25 incident was not reported to the Department until 8/11/25 at 11:15 a.m., which exceeded the 24-hour reporting requirement.”

“Fire drill records are missing from August 2024 through January 2025, indicating the facility failed to maintain documentation of required fire drills and that a detector was operative.”

“Residents admitted have not been educated regarding their right to refuse medication if they believe that there may be a medication error.”

“Resident-home contracts were not signed by residents at admission. Multiple contracts existed for residents without resident signatures, indicating failure to comply with contract signature requirements at or before admission.”

“A bedrail in bedroom 114 has an opening measuring 18" x 10" that is uncovered, posing an entrapment hazard for the resident.”

“Incorrect date and time were recorded on a resident's glucometer, indicating improper storage and management procedures for medical equipment.”

“A resident's initial support plan did not address the use of a bedrail including safety precautions, risks, and education, indicating the support plan was incomplete.”

“Residents who participated in the development of their support plans did not sign the support plan documents as required.”

“Facility failed to report suspected abuse to the local Area Agency on Aging as required by the Older Adult Protective Services Act. On 7/18/24 at approximately 2:00 am, resident #1 was found in resident #2's bedroom and allegedly asked to get into bed and touch, causing resident #2 to be upset and scared. The report was made to the home at 9:00 am but was not reported to the AAA.”

“Resident #1 admitted to the Secure Dementia Care Unit (SDCU) but the medical evaluation completed does not include a diagnosis of Alzheimer's disease or other dementia as required. Resident #2 was admitted to the SDCU but a medical evaluation was not completed within 60 days prior to admission.”

“Resident #2 was admitted to the SDCU but no written cognitive preadmission screening completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission on the Department's preadmission screening form.”

“Resident #1 and Resident #2 were admitted to the SDCU but the home has no documentation that the resident and the resident's designated person have not objected to the admission or transfer to the secured dementia care unit.”

“Facility issued a FIRST PROVISIONAL license due to violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes).”