Knickerbocker Villa.

“A sign stating "Please wait for assistance for going back to your room. YOU ARE A FALL RISK" was placed on the dining room table where resident #1 had meals, failing to treat the resident with dignity and respect.”

“A newly hired staff person (Staff person A) did not have a Pennsylvania criminal background check requested in accordance with the Older Adult Protective Services Act.”

“Staffing was insufficient to meet resident needs. The home served 32 residents with 12 having mobility needs and 2 requiring two-person assistance for transfers, and staff interviews indicated inability to meet resident needs due to lack of available direct care staff.”

“Resident #4 did not have access to a source of light that can be turned on/off at bedside.”

“Fire drills were not held in compliance with regulations. The home routinely schedules 2 staff on the overnight shift, but for the past year, the minimum number of staff participating in sleeping time fire drills was 3 staff, violating the requirement that drills not be routinely held when additional staff are present.”

“A staff person was observed on resident nannie cam entering the resident's locked bedroom through a shared bathroom door on multiple occasions while the resident was hospitalized, and was seen going through the resident's nightstand drawer, attempting to open a locked desk, taking drinks from the resident's refrigerator, and spraying the resident's perfume. The resident's perfume went missing during this time.”

“A staff person was observed on resident nannie cam entering the resident's locked bedroom through a shared bathroom door on multiple occasions while the resident was hospitalized, and was seen going through the resident's nightstand drawer, attempting to open a locked desk, taking drinks from the resident's refrigerator, and spraying the resident's perfume, violating the resident's right to privacy of possessions.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. The staff person held a high school diploma from the Republic of Indonesia, but the facility did not request a waiver from the Department for this non-US educational institution.”

“The resident assessment did not include the diagnoses of Seizures and Unspecified Falls as indicated on the medical evaluation, despite the resident having a significant change in condition requiring an additional assessment.”

“Resident with documented ability to eat/drink independently did not receive required monitoring assistance from 2/26/25 to 3/12/25. Resident was observed as non-adherent with eating, presented with weakness and diarrhea, and was hospitalized. Staff failed to report decline in eating/drinking to Care Coordinator or Administrator.”

“Home served residents with mobility needs in secure dementia unit and personal care unit with only 2 staff present from 7:45 p.m. to 7:00 a.m., which is inadequate to provide assistance with activities of daily living and safe emergency evacuation within the maximum evacuation time of 5 minutes.”

“Resident prescribed twice-daily blood sugar tests did not receive testing from 9:00 p.m. to 6:00 a.m. on specified dates. Medication administration record on 4/7/25 at 8:00 p.m. does not document blood sugar test result or amount of insulin administered.”

“Resident's assessment was not updated when resident began refusing to eat and ability to eat/drink independently declined, resulting in delayed assessment update. Another resident's assessment did not reflect documented verbal and physical aggression observed by multiple staff, despite facility responsibility to update assessments when resident condition significantly changes.”

“Home issued a 30-day discharge notice for nonpayment on a date when the resident's account balance was actually paid in full, violating the grounds for discharge which require documented nonpayment before issuing such notice.”

“At 10:49 a.m., there was no thermometer in the main refrigerator in the kitchen.”

“Resident #3's mattress had two approximately 1-inch tears, one of which exposed a sharp end of a metal spring.”

“Four resident contracts (residents #1, #2, #3, #4) did not include fee schedules listing actual amounts charged for available personal needs services.”

“From 7:30 p.m. on 2/18/25 to 3:00 a.m. on 2/19/25, with 30 residents present, no staff persons in the home were certified in first aid, obstructed airway techniques, and CPR, violating the requirement of at least one certified person per 50 residents.”

“The ceiling in the small conference room was actively leaking a dark brown substance, staining two ceiling tiles with one hanging down approximately 8 inches, and leaking into a half-full 5-gallon bucket throughout the day.”

“At 11:15 a.m., the exterior walkway outside emergency exit door #6 was covered with approximately 2 inches of snow and ice.”

“At 11:05 a.m., approximately 2 inches of snow and ice on the exterior walkway obstructed emergency exit door #6, which could only be opened approximately 8 inches.”

“Resident #2's medication administration record contained inaccurate blood glucose readings that did not match actual glucometer readings, including a documented reading of 146 when the actual reading was 198, and documented readings of 300 that were not on the resident's glucometer.”