Lecom Parkside at Glenwood.

“Facility failed to immediately report suspected abuse to the local Area Agency on Aging within 24 hours. A non-verbal resident with mobility needs fell from a recliner and sustained injuries (cut to nose and bloody lip) when staff failed to put up footrests as required. The incident was not reported to the Area Agency on Aging until the following day at 3:00 p.m., violating the Older Adult Protective Services Act reporting requirements.”

“Facility failed to report an incident (resident fall resulting in injury) to the Department of Human Services within 24 hours in the manner designated by the Department. A non-verbal resident fell from a recliner when staff failed to secure the footrests, sustaining a cut to the nose and bloody lip.”

“Resident was neglected when staff failed to put up footrests on a recliner as required by the care plan, resulting in the resident falling and sustaining injuries (cut to nose and bloody lip). A non-verbal resident with total physical assistance needs and a history of repeated falls was left unsupervised after the fall with the bedroom door closed and lights off.”

“Support plans for three residents did not address identified safety needs: one plan did not address use of bed bolsters (purpose, frequency, responsibility); another did not address use of a lap belt (purpose, frequency, responsibility); and a third did not address that the resident's apartment door should remain open when the resident is in the room without staff.”

“A resident bit another resident on the pinky finger, breaking the skin, during a dispute over a television remote in the common area. The injured resident received first aid and prescribed treatment for the wound.”

“Two residents did not sign their resident home contracts as required. Resident #1 did not sign the contract dated /24, and Resident #2 did not sign the contract dated /25.”

“Two direct care staff members did not receive the required 12 hours of annual training in 2024. Direct care staff member A received only 9 hours 45 minutes, and direct care staff member B received only 9 hours of training in the January to December 2024 training year. This is a repeat violation from 11/21/2024.”

“Ancillary staff member C did not receive required annual training in 2024 on five topics: fire safety, emergency preparedness procedures, resident rights, Older Adult Protective Services Act, and falls and accident prevention. This is a repeat violation from 11/21/2024.”

“On 01/01/2025 at approximately 8:00 p.m., staff person A sat on resident #1 while straddling the resident's legs on the edge of the bed and held both of the resident's arms down while staff person B put on an incontinence brief. The resident was physically unable to get up off the bed during this incident, constituting a manual restraint.”

“On 01/01/2025 at approximately 8:00 p.m., staff person A sat on resident #1 while straddling the resident's legs on the edge of the bed and held both of the resident's arms down while staff person B put on an incontinence brief. This manual restraint restricted the resident's ability to move arms, legs and other body parts freely.”

“Resident #1's Novolog Flexpen was opened but not dated with the open date. According to manufacturer instructions, Novolog Flexpen expires 28 days after opening, requiring proper dating for tracking expiration.”

“Resident #1's Novolog Flexpen and Lantus Solostar and resident #2's Kwikpen did not have pharmacy labels indicating resident name, medication name, prescription date, dosage, administration instructions, and prescriber name/title. Additionally, resident #2's DM Syrup label was incorrect, resident #3's saline solution was mislabeled as Deep Sea, and resident #2's ketoconazole shampoo label indicated incorrect frequency.”

“Family reported an allegation of abuse to staff at approximately 5:44 p.m., but the facility did not report this allegation to the Department until 7:30 p.m. on 9/30/24, which exceeded the required 24-hour reporting timeframe.”

“A resident's apartment had strong urine odor with an open urinal bottle containing 2-4 inches of urine on the bedside table and a urine stain on the bedroom carpet measuring approximately 10 inches long. Sanitary conditions were not maintained in the resident's living area.”

“The facility did not follow its system to safeguard resident laundry from misplacement or loss. A resident lost multiple clothing items because not all clothing items were labeled as required by the facility's policy.”

“A resident's initial support plan indicated the resident was independent in the care and wearing of hearing aids; however, the resident had a documented history of removing, not wearing, and losing hearing aids and was unable to hear well without them. The support plan was not updated to reflect the resident's actual care needs.”

“Resident medication labels did not match prescribed dosages and frequencies. One resident's label indicated medication to be given every 2 hours as needed when prescribed every 6 hours; another resident's label indicated incorrect medication and frequency for pain management versus shortness of breath treatment.”

“Resident's support plan did not document physical interventions used by staff. Staff were trained to place a hand on the resident's back as a physical intervention to guide and redirect the resident, but this technique was not included in the resident's support plan.”

“A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any way. On 5/9/24, only one direct care staff person was working in the Secure Dementia Care Unit (SDCU) despite 16 residents requiring supervision. Staff discovered two residents with moderate supervision needs and orientation problems engaging in sexual activity in a locked bedroom, indicating inadequate supervision.”

“Staffing shall be provided to meet the needs of the residents as specified in the resident's assessment and support plan. On 5/9/24 from 2:00 p.m. to 4:30 p.m., only one direct care staff person was working in the SDCU despite two direct care staff being regularly scheduled, leaving 16 residents requiring supervision inadequately staffed.”

“Staff member A failed to correctly identify resident #1's prescribed medications before removing and administering two medications prescribed to resident #2 to resident #1.”

“Resident #1 was administered two medications that were prescribed to resident #2, in violation of following the prescriber's orders.”

“Two residents admitted to the facility did not have resident-home contracts completed with the new legal entity upon the change of legal entity.”

“Administrator failed to provide immediate access to staff records for staff persons A and B upon request by Department agent on inspection date. Records were still not provided on follow-up date.”

“Facility used term 'assisted living' in resident monthly statement (August 2023) and resident billing documents despite not being licensed as an assisted living residence, violating Act 56 of 2007. Additionally, required influenza awareness poster was not posted in a public place.”

“Staff person A, hired on specified date, did not have a Pennsylvania State Police criminal background check completed in accordance with the Older Adult Protective Services Act.”

“Direct care staff persons A and B do not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required for direct care staff qualifications.”

“Staff person B, hired on specified date, did not receive first day orientation training in general fire safety and emergency preparedness as required before or during the first work day.”

“Direct care staff persons A and B, hired on specified dates, provided unsupervised ADL services without completing the Department-approved direct care training course and passing the competency test as required.”

“Staff physically removed a resident from the dining room by dragging him while seated in a chair without wheels into the lobby on multiple occasions, including the morning of the inspection, violating the requirement to treat residents with dignity and respect.”

“A staff member lifted a resident to a standing position while the resident's hands were in her pants pockets and refusing care. The resident fell, sustaining approximately 4 inch and 6 inch skin tears on her forearms and a hematoma on her left upper arm, requiring emergency room treatment. The incident was investigated and determined to be accidental.”