The Residence at Presque Isle Bay.

“Resident-to-resident abuse occurred on multiple occasions. On 11/8/25, a resident struck another resident across the cheek with sufficient force, leaving a visible red handprint, and struck a third resident in the nose. On 11/30/25, the same resident grabbed, shook, and slapped other residents, causing visible marks and emotional distress.”

“Sprinkler system malfunction on 12/10/25 caused pipe burst and significant water damage. As of 1/5/26, ceiling panels in Primary Kitchen remained unreplaced, Resident Room 222 required complete demolition, bathroom ceiling in Room 221 unreplaced, baseboards in Rooms 321 and 322 unattached, and Florida Room required full demolition and replacement.”

“Home did not implement sufficient positive interventions to modify or eliminate physically aggressive behaviors of resident. Resident engaged in multiple episodes of grabbing, shaking, and slapping other residents without adequate de-escalation techniques being employed.”

“A resident's assessment dated 10/27/25 indicated no aggression issues, but the resident verbally threatened another resident on 11/1/25 and pushed another resident to the floor on an unspecified date, causing injury. Staff failed to update the resident's assessment and support plan to address the significant behavioral changes and aggression towards the other resident.”

“A resident's support plan dated 10/27/25 indicated no aggression problem, but the resident engaged in multiple verbal threats and physical aggression toward another resident requiring injury treatment. Staff staggered the residents' mealtimes to limit aggressive acts, but this intervention was not documented in the resident's support plan.”

“A resident's previous medical evaluation was completed on 6/28/23, exceeding the required annual interval. The facility failed to ensure timely annual medical evaluations.”

“A resident exhibited significant behavioral changes over 2-3 months including yelling, foul language, punching staff, and throwing dining ware, but the resident's assessment did not document these changes despite the requirement for additional assessments when resident condition significantly changes.”

“A resident who returned from hospitalization on approximately 3:00 a.m. was prescribed medication (800mg every 12 hours for 5 days starting 1/13/25) that was never administered. The resident was found on the floor naked from the waist down, shivering and unresponsive on a subsequent date, was hospitalized with multiple diagnoses, and subsequently died. Staff interviews indicated the resident was rarely getting out of bed and had difficulty accepting fluids or food intake during this period.”

“A resident was prescribed medication (800mg every 12 hours for 5 days) that was never administered despite the prescriber's orders. The resident subsequently was found unresponsive on the floor and was hospitalized, ultimately resulting in death.”

“The resident's support plan did not document how medical needs (Depression, Kidney Disease, Neuropathy, and Hypertension) identified in the assessment would be met or addressed through services or referrals.”

“The resident's support plan did not document how medical needs (Depression, Kidney Disease, Neuropathy, and Hypertension) identified in the assessment would be met or addressed through services or referrals.”

“Approximately 200 bed bugs were found between the mattresses of a resident's bed, with the resident having multiple bite marks and reddened areas on both arms, indicating evidence of insect infestation in the home.”

“Resident #2's most recent medical evaluation was not current; the resident did not have an annual medical evaluation completed as required.”

“Resident #2 and Resident #3 were admitted to the Secured Dementia Care Unit without written cognitive preadmission screenings completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission.”

“Home failed to report an incident to the Department within 24 hours. On April 15, 2024 at approximately 10:16 p.m., a resident was found in a private bathroom with a laundry bag string around their neck, prompting a call to the Crisis hotline, but the home did not report this incident to DHS as required.”

“Resident neglect through failure to assess and implement adequate fall prevention services. A resident assessed as independent in ambulation and bed/chair transfers experienced multiple falls resulting in hospitalizations for hip fracture, suspected concussion/closed head injury, and rib fractures, yet the home failed to reassess care needs or implement appropriate protective measures.”

“Home failed to schedule required follow-up medical appointments after resident hospitalizations. Following two separate falls and hospital discharges, the home did not schedule required follow-up appointments with internal medicine specialist (within 3 days) and primary care physician (within 2-3 days) as indicated in discharge instructions.”

“Home failed to conduct additional assessments when resident's condition significantly changed. A resident assessed as independent in bed/chair transfers experienced two falls from bed resulting in hospitalizations, but the home did not complete a reassessment of the resident's transfer needs or change in condition.”

“The facility violated requirements related to resident services or care documentation.”

“The facility's certificate of compliance was REVOKED and a FIRST PROVISIONAL license was issued based on violations of 55 Pa Code Ch. 2600. The provisional license is valid from June 11, 2024 to December 11, 2024.”

“The facility's certificate of compliance was REVOKED and a FIRST PROVISIONAL license was issued based on violations of 55 Pa Code Ch. 2600. The provisional license is valid from June 11, 2024 to December 11, 2024.”

“Suspected abuse of residents was not immediately reported to the Area Agency on Aging. On 10/16/23, a pre-paid debit card was reported stolen and misused, but this incident was not reported to AOA until 10/25/23. Additionally, a separate incident in the secured dementia care unit between 10/5/23-10/11/23 involving potential inappropriate conduct between residents was reported internally but not reported to AOA.”

“An incident involving a stolen and misused pre-paid debit card reported on 10/16/23 was not reported to the Department within 24 hours; it was not reported until 10/25/23, nine days later.”

“The facility failed to maintain proper incident investigation procedures in accordance with regulatory requirements.”

“The facility violated requirements related to staff training or qualifications.”

“A resident requested assistance with toileting activities. A staff member abruptly grabbed the resident's upper right arm, partially rotating their body toward a recliner chair, which caused the resident significant pain, a feeling of disrespect, and fear of further harm. The resident was not treated with dignity and respect.”

“A resident's most recent documented medical evaluation was completed on 1/19/24 but was not signed by a medical professional, failing to meet the requirement that medical evaluations be documented and signed by a physician, physician's assistant, or certified registered nurse practitioner.”

“A resident was observed choking on a cheeseburger approximately one month prior to a fatal choking incident, but was not evaluated to determine appropriate diet consistency. Additionally, the resident's assessment indicated independence with eating and toileting despite requiring significant physical assistance for both activities, and a significant change regarding VNA Hospice care was noted without indicating what services would be provided.”

“There was no access code posted at the main exit/entrance point of the home's secured dementia care unit, failing to provide conspicuous directions for the operation of the key-locking device.”

“The facility's certificate of compliance was REVOKED and a FIRST PROVISIONAL license was issued based on violations of 55 Pa Code Ch. 2600. The provisional license is valid from June 11, 2024 to December 11, 2024.”

“The facility's certificate of compliance was REVOKED and a FIRST PROVISIONAL license was issued based on violations of 55 Pa Code Ch. 2600. The provisional license is valid from June 11, 2024 to December 11, 2024.”

“Suspected abuse of residents was not immediately reported to the Area Agency on Aging. On 10/16/23, a pre-paid debit card was reported stolen and misused, but this incident was not reported to AOA until 10/25/23. Additionally, a separate incident in the secured dementia care unit between 10/5/23-10/11/23 involving potential inappropriate conduct between residents was reported internally but not reported to AOA.”

“An incident involving a stolen and misused pre-paid debit card reported on 10/16/23 was not reported to the Department within 24 hours; it was not reported until 10/25/23, nine days later.”

“The facility failed to maintain proper incident investigation procedures in accordance with regulatory requirements.”

“The facility violated requirements related to resident services or care documentation.”

“The facility violated requirements related to staff training or qualifications.”

“Two staff members on the secured dementia unit were both occupied with one resident's incontinence care for approximately 5 minutes with the resident's door closed, leaving 15 remaining residents unsupervised. Multiple staff indicated that two staff are routinely scheduled during waking hours on this unit, and residents #1, #2, #3, and #4 require two staff members for hygiene and personal care services.”