Colonial Courtyard at Clearfield.

“A resident was physically assaulted by another resident in the dining room—shaken, hit in the head, and grabbed by the wrists. Staff witnessed the incident but the victim became hysterical, screaming, crying, and remained scared and agitated afterward. The facility failed to ensure the resident was treated with dignity and respect.”

“The facility failed to follow its medication storage policy for controlled substances. Multiple residents' medications lacked proper documentation: count sheets were missing signatures, dates, staff names, or documentation of administration, resulting in numerous tablets being unaccounted for across five residents (30 tablets, 30 tablets, 18 tablets, 24 tablets, and 15 tablets respectively).”

“The facility failed to follow prescriber's orders for multiple residents. Five residents did not receive prescribed medications at their scheduled times: one resident missed a half tablet once daily dose, one missed a bedtime tablet, one missed three doses of a three-times-daily medication, one missed an 8:00 a.m. dose of a twice-daily medication, and one resident missed an 8:00 p.m. dose of a twice-daily medication.”

“The resident's support plan documented that the resident had an altercation with another resident requiring hospitalization for evaluation, but the plan failed to address how the resident's behavioral needs would be met at the residence, missing a critical required element of the support plan.”

“The residence failed to immediately report a suspected abuse allegation involving a staff member to the local Area Agency on Aging. The allegation was not reported until after the initial discovery, violating the requirement for immediate reporting under the Older Adult Protective Services Act.”

“After an allegation of abuse by a staff member was made, the staff member continued to provide services to residents on multiple dates without an approved plan of supervision from the department, violating the requirement to immediately suspend or develop a supervision plan.”

“The residence failed to report an abuse allegation involving a staff member to the Department within the required 24-hour timeframe. The department was not notified until after the initial discovery of the allegation.”

“A staff member performed an improper one-person transfer of a resident with limited mobility by pulling the resident up by the arms, causing significant pain (7/10) and resulting in the resident falling to the floor. The resident subsequently suffered an acute impacted fracture at the base of the humerus of the left shoulder with slight inferior subluxation, constituting neglect and abuse.”

“Resident #1's bed cane was not secured to the bed, allowing the bed cane to move/tip side to side approximately 10 inches causing a potential fall risk.”

“There was an approximate 1/8-inch accumulation of lint in the lint trap of the first commercial dryer in the main laundry room.”

“Direct care staff person A did not receive training in medication self-administration during the training year 1/1/24 to 12/31/24.”

“The residence has a safe evacuation time of 15 minutes, 0 seconds established on 6/27/23, but on 4/25/24 at 4:25 AM residents evacuated in 15 minutes and 0.0024 seconds exceeding the established time. This is a repeat violation from 1/25/24.”

“During the fire drill on 6/25/24 at 4:25 AM, 58 residents were present in the home; however, only 56 residents evacuated to the designated meeting place.”

“During a fire drill conducted on 12/26/23, residents were not evacuated within the facility's maximum safe evacuation time of 15 minutes. The drill took 15 minutes 20 seconds to complete, exceeding the required timeframe by 20 seconds.”

“Resident #6's insulin was stored in the refrigerator with an open date, but manufacturer's instructions required storage at room temperature after opening.”

“Resident #6's insulin container pharmacy label indicated 'Please see attached for detailed directions' but no directions were attached to the container.”

“Resident #6's prescribed medication was not administered because it was not available in the residence, failing to follow the prescriber's order for daily administration.”

“Resident #6's support plan did not document specific risks associated with a prescribed mobile couch cane or the resident's ability to use the device safely, despite the assessment indicating a need for the device.”

“The support plan for resident #1 does not adequately address how the home will meet the resident's need for supervision.”

“The facility failed to report an incident to the Department within 24 hours. On the inspection date, staff observed resident #1 pushing resident #2 by the shoulders, causing resident #2 to stumble backward. The residents had multiple physical altercations since 5/10/23, but the home did not report this incident to the Department.”

“Residents #1 and #2 experienced multiple physical altercations with each other, including kicking, pushing, and falling incidents. The facility failed to implement adequate safety precautions to prevent abuse/neglect, including incidents where resident #2 was kicked, pushed causing a fall with head injury requiring hospitalization, and pushed with red marks observed on arms.”

“Annual assessments were inaccurate and did not reflect residents' actual conditions. Resident #1's assessment indicated minimal aggression problems despite four physical altercations; Resident #2's assessment indicated minimal orientation/judgment issues despite wandering into other residents' bedrooms; and Resident #3's assessment indicated safe independent ambulation despite multiple falls during transfers.”

“Resident #1 had 6 Tums tablets found on the floor under the dresser and recliner chair. The resident had not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding the ability to self-administer medications.”

“The support plan for Resident #1 dated 6/23 does not address the resident's need for assistance with a Foley Catheter and how the home will meet this need.”