Keystone Villa at Douglassville Personal Care.

“A resident bit another resident on the hand, breaking skin and causing injury requiring hospitalization, antibiotics, and a follow-up hospital admission for infection. The incident occurred when one resident fell off a sofa arm onto another resident in the memory care common area.”

“Staff person A initialed the medication administration record without administering the prescribed medication to the resident at the scheduled time of 12:00 p.m. The information required by subsection (a)(13) and (14) was not recorded at the time medication was administered.”

“Resident prescribed a medication 3 times daily with meals was not administered the prescribed medication on the specified date at 12:00 p.m., resulting in failure to follow the prescriber's orders.”

“An unlabeled used bar of soap was present in resident #2 and #3's shared shower, violating the requirement that bar soap must be clearly labeled for each resident who shares a bathroom.”

“A medication bottle containing resident information was observed on top of an unlocked, unattended medication cart near the first floor dining room, violating resident record confidentiality requirements.”

“Resident #8's oxygen tank was stored on the floor without a secure storage container or cart to prevent tipping.”

“Sanitary conditions were not maintained: black and brown granular substance (spilled coffee and grounds) were found under the first-floor dining area kitchenette sink, and a full wastepaper basket with dirty Depends and feces on a toilet seat rim were found in resident #1's bedroom.”

“A full, uncovered tall trash can was present in resident #2 and #3's shared bathroom, failing to prevent the penetration of insects and rodents.”

“The home's dumpster lid was observed uncovered, failing to prevent the penetration of insects and rodents.”

“Two undated takeout pizza boxes were found in the 2nd floor kitchenette refrigerator. This was a repeat violation from 8/6/24.”

“Hydrocortisone 1% Cream prescribed for Resident #5 remained in the home's medication cart despite being discontinued on 9/14/2025.”

“Staff person who has not successfully completed the Department-approved medication administration course administered eye drops to a resident. Only authorized personnel (physicians, nurses, physician's assistants, paramedics, or staff certified in medication administration training) are permitted to administer prescription medications.”

“Eye drops were located in an unlocked cabinet in a resident's room in the secured dementia care unit. Prescription medications, OTC medications, and syringes must be kept in a locked area or container, including medications stored in residents' rooms.”

“A resident was admitted to the Secure Dementia Care Unit without a written cognitive preadmission screening completed within 72 hours prior to admission as required.”

“Resident in secure unit with total physical assistance need for toileting was not toileted every 2 hours as indicated in their Assessment and Support plan on 27 different occasions between unspecified dates.”

“Resident in secure dementia unit reported being punched in head twice and pushed by staff member. Staff found resident disheveled with skin tear on elbow. Investigation determined abuse allegation was unfounded; staff member was terminated for insubordination.”

“The resident's support plan was not updated to reflect hospice services received or the need for additional care from a private duty aide due to mobility and transfer needs.”

“Resident admitted to the Secured Dementia Care Unit did not have an initial Resident Assessment Support Plan completed within 72 hours of admission as required.”

“A resident yelled at another resident and pinned them against the wall after grabbing their arm. The resident was frightened and anxious after the incident.”

“A third shift staff member entered a resident's room and pulled down the sheet to check if a brief change was needed without first addressing the resident or explaining the reason for touching the resident's leg, violating the resident's dignity and respect.”

“A resident reported that staff member pulled their arm resulting in a large red lump on their lower right arm, and the staff member yelled at the resident. The investigation was inconclusive, but the employee's employment was terminated out of an abundance of caution.”

“A resident physically aggressed another resident by slapping their arm without provocation. This was the second incident of physical aggression to other residents without provocation within 3 days, despite increased medication dosage and additional supervision being in place.”

“Resident's Assessment and Support Plan was not updated to reflect a change in medication administration status from self-administered to staff-administered with trained staff storage and administration.”