The Garden at Pine Run Health Center.

“A resident with moderate wandering needs was treated disrespectfully during dinner service when a direct care staff person repeatedly ordered the resident to sit down in a loud voice multiple times, despite the resident's known preference not to sit at the table. Other residents, families, and staff reported the staff person's approach was not respectful of the resident's dignity.”

“Direct care staff persons A and B did not receive required training in infection control during training year 2024. This is a repeat violation.”

“Direct care staff persons A and B did not receive required annual training in fire safety, emergency preparedness procedures, or the Older Adult Protective Services Act during training year 2024. This is a repeat violation.”

“Narcotics logs for medication carts were left unsecured on top of the medication carts, creating a confidentiality and security breach of resident records.”

“Direct care staff person A did not receive required annual training in infection control, general cleanliness and hygiene principles, and areas associated with immobility such as prevention of decubitus ulcers, incontinence, malnutrition and dehydration during the 2024 training year.”

“Staff person A did not receive required annual training in fire safety, emergency preparedness procedures and crisis response, or training on the Older Adult Protective Services Act during the 2024 training year.”

“The trash can in the memory care kitchenette was uncovered and not in use, failing to prevent penetration of insects and rodents.”

“An unlabeled and undated plate of breakfast food including eggs, pancakes and sausage was found in the kitchenette refrigerator, violating proper food storage and labeling requirements.”

“The home's written emergency procedures have not been submitted to the local emergency management agency since February 9, 2024, failing to meet the annual submission requirement.”

“During the fire drill on June 21, 2025, only 13 of 29 residents evacuated to a fire-safe area away from the building, failing to meet the requirement that all residents evacuate to a designated meeting place.”

“Medication cards were observed with punctured blister foil exposing medications to contamination and improper sanitation conditions.”

“Resident #1 passed away and their personal belongings were removed, but the remainder of previously paid charges was not credited to the spouse's account within 30 days as required by regulation and the Elder Care Payment Restitution Act.”

“Colgate Optic White toothpaste with a poison control warning label was unlocked, unattended, and accessible to residents in room #507. Not all residents of the home have been assessed as capable of safely recognizing and using poisonous materials.”

“Emergency telephone numbers, including the nearest hospital and fire department, were not posted on or by the telephone in room #507.”

“The home's last written notification to the local fire department was completed in 2016; however, the home had a change in ownership in 2023 requiring a new letter with the address, location of bedrooms, and evacuation assistance needs to be sent.”

“Eye drops prescribed for resident #2 were in the home's medication cart despite being discontinued. Additionally, another prescription for resident #2 issued on a date after the medication was on the home's medication cart. This is a repeat violation from 12/28/23.”

“Prescription medications were not properly labeled according to pharmacy label requirements. Staff were signing out standing orders from PRN cards without a direction change sticker on the pharmacy label, failing to clearly indicate the prescribed dosage and instructions for administration.”

“A package of OTC medication was in the medication cart and was not labeled with the resident's name. The home could not verify who the medication belonged to.”

“Strong odor of urine was evident in hall by resident room and emergency exit leading to patio. Dried feces were found on the lifted toilet seat in resident's bathroom.”

“A prescribed medication was in the home's medication cart; however, the medication was discontinued and should have been removed.”

“A package of OTC medication was in the medication cart and was not labeled with the resident's name. The home could not verify who the medication belonged to.”

“Staff person did not complete the controlled substance log for the morning medication pass and completed it only when Department agents explained a medication audit would be conducted. Additionally, a resident's glucometer reading showed a discrepancy with the documented MAR, and a medication administration was not recorded on the MAR for a resident on the morning.”

“Strong odor of urine was evident in hall by resident room and emergency exit leading to patio. Dried feces were found on the lifted toilet seat in resident's bathroom.”

“A prescribed medication was in the home's medication cart; however, the medication was discontinued and should have been removed.”

“Staff person did not complete the controlled substance log for the morning medication pass and completed it only when Department agents explained a medication audit would be conducted. Additionally, a resident's glucometer reading showed a discrepancy with the documented MAR, and a medication administration was not recorded on the MAR for a resident on the morning.”

“A resident's medication administration record stated a prescribed solution was for pain and shortness of breath, but the physician order indicated it was for anxiety and restlessness as needed.”

“A resident's medication administration record stated a prescribed solution was for pain and shortness of breath, but the physician order indicated it was for anxiety and restlessness as needed.”

“Medication administration records were not properly documented at the time medications were administered. One resident's tablet was not signed out on the scheduled time but the MAR was initialed, and on another date the medication was signed out and administered but the MAR was not initialed. Another resident's bedtime medication was not signed out or administered but the MAR was initialed.”