Arbor Terrace Exton.

“Video cameras on home exits and entrances were recording 24 hours, but signage posted on the entrance and throughout the building did not state that cameras were recording.”

“The home's staff training plan does not include dates, locations and times.”

“A bottle of soap with a label indicating "This is not food, do not eat, use only as directed" was unlocked, unattended, and accessible to residents in Memory care unit room 119. Additionally, a maintenance cart with paint was left unattended in the Memory care unit hallway. Not all residents have been assessed capable of recognizing and using poisons safely. This is a repeat violation from 1/24/2025.”

“There was dirt buildup on the memory care kitchenette sink.”

“There was a half full, uncovered, unattended trash can in the 2nd floor kitchenette.”

“There were metal signs and boxes located outside of the dumpster.”

“The home does not have a current certificate of operation from the Department of Labor and Industry or appropriate local building authority for elevators and lifting devices. The last certificate expired on January 31, 2025.”

“There were unlabeled, undated bags of Tots, sweet potatoes, and french fries in the main kitchen freezer.”

“The temperature in the Memory care kitchenette freezer was 26 degrees Fahrenheit (should be 0°F or below). There was no thermometer in the main kitchen ice cream freezer. There was no thermometer in the second-floor kitchenette freezer.”

“The home's emergency procedures are not posted in a conspicuous and public place in the home. The procedures were located in the drawer behind the receptionist desk.”

“A resident's medication administration record for March 2025 does not include the initials of the staff person who administered a tablet at 6 am on a specified date.”

“Resident with history of wandering was able to elope from the Secured Dementia Care Unit by breaking window locks and exiting through a bedroom window. The resident was found a half mile away at a business after walking across multiple roads in 39-degree weather with inadequate clothing, crossing a 4-lane road and two intersections without sidewalks. The facility grounds lack fencing to prevent residents from accessing Route 30, a 5-lane highway.”

“The exit door located at Stairway 3 would not open after the delayed release bar was held for 30 seconds, blocking egress from the stairway exit.”

“A resident who participated in the development of their support plan did not sign the support plan as required.”

“Incorrect instructions were posted next to exit doors from the home's 2nd, 3rd and 4th stairwells on the second and third floor in Bridges Memory Care and Personal Care and at the main gate in the Memory Care area patio, where key-locking devices are used to prevent immediate egress.”

“Staff member hired was not compliant with criminal background check requirements. The employee resided outside Pennsylvania and a FBI check was not requested by the date of hire, and a completed PA State Criminal Background Check was not obtained.”

“Resident assessment was not properly completed when the resident experienced a significant condition change with increased agitation. The assessment noted the change but did not indicate the resident's needs or service plan, with these sections left blank or marked 'n/a'.”

“Pantene shampoo and Ivory body wash were unlocked, unattended, and accessible to residents. Not all residents of the home have been assessed as capable of recognizing and using poisons safely.”

“Resident readings were incorrectly documented in the medication administration record (MAR) on multiple occasions, including readings documented at incorrect times and values.”

“A resident's narcotic medication was signed out on the controlled substance log on 10/9/2024 at 7:00 pm but the medication administration record did not include the initials of the staff person who administered the medication.”

“Prescribed medications for two residents were not available in the home at the time they were needed for administration, preventing the home from following prescriber's orders.”

“A resident was administered medication prescribed for anxiety to control behaviors on three occasions (6/28/2024, 7/12/2024, and 8/1/2024) without documentation of safe management techniques and interventions being employed first, constituting use of medication as a restraint. This was a repeat violation from 4/24/2024.”

“Direct care staff person A did not receive required annual training in medication self-administration during the 2023 training year.”

“Staff person B did not receive required annual training in the Older Adult Protective Services Act (35 P.S. §§ 10225.101—10225.5102) or in falls and accident prevention during the 2023 training year.”

“A resident's medical evaluation dated 8/7/2024 did not include health status, which is a required component of the medical evaluation.”

“A resident's prescription medication with an open date of 6/15 was found in the medication cart during inspection and should have been disposed of 4 weeks after opening per manufacturer's instructions.”

“A resident's prescription was changed from one tablet by mouth every 4 hours as needed to one tablet by mouth two times a day, but there was no change sticker on the prescription bubble pack indicating the prescription change.”

“A discrepancy was discovered in a resident's controlled substance medication count at 11:05 AM where the quantity in the bubble pack (28 tablets) did not match the controlled substance register (27 tablets), indicating a missed dose or medication error that was not properly documented.”

“The home's Authorized Electronic Monitoring Policy required residents to obtain written consent from the community before installing electronic monitoring devices, which violated residents' rights to install devices in their private rooms without permission.”

“Staff Member A's criminal background check was not completed prior to hire; the background check was not finished until 5/9/2023.”

“Direct care staff persons A and B did not receive required annual training on medication self-administration and instruction on meeting resident needs as described in assessment tools and support plans during training year 2023.”

“Staff person A did not receive required annual training in fire safety completed by a fire safety expert and training on the Older Adult Protective Services Act during training year 2023.”

“Multiple air conditioning units in resident rooms became inoperable for extended periods and were not promptly replaced or repaired, creating unsafe living conditions.”

“On 7/15/2024, a laundry basket in the Evergreen laundry room contained clothing items that were mostly unlabeled with residents' names or room numbers, creating risk of loss or misplacement.”

“A resident prescribed 1,000 units of Vitamin D3 daily was administered 2,000 units daily from 6/1/2024 to 7/14/2024 (except 6/16/24 and 6/21/24), contrary to the prescriber's orders.”

“The home did not report an incident of alleged abuse by a resident's spouse (punching and verbal abuse) to the Department within 24 hours as required. The incident was not reported until 5/21/2024.”

“A resident was physically abused (punched multiple times) and verbally abused by their spouse, who called the resident derogatory names. The resident had multiple bruising spots on their legs and expressed fear and pain, but the home never addressed these concerns or the bruising.”

“Staff person B disrespected a resident by rummaging through the resident's belongings, turning up the television volume loudly to wake the resident, and then ignoring the resident's request to turn it back down.”

“Medications were administered in the medication wellness office with multiple residents present, denying residents privacy during medication administration. Residents were also not provided privacy when discussing their medications with medication technicians.”

“A resident was admitted to the home; however, the preadmission screening form was completed more than 30 days prior to admission, failing to meet the requirement that the determination be made within 30 days before admission.”

“An individual (the Assessor) who participated in the development of a resident's support plan did not sign and date the support plan as required.”

“Staff member removed resident's bedding and woke them abruptly without dignity or respect, standing across the room rather than assisting the resident as needed.”

“Resident record does not include a record of incident reports for the individual resident. The reportable incident was located in the resident's financial record in the Business Office rather than in the resident's medical chart.”

“The home failed to provide heating to the residents in the dining room and to one resident in their apartment for at least two weeks, as contracted for in the resident-home contract.”

“The dining room area on the first floor utilized by residents was colder than 62 degrees Fahrenheit. The heating system in one resident's apartment had been broken for a couple of weeks, failing to maintain the required minimum indoor temperature of 70°F.”

“Three portable space heaters were found in the facility. Two had metal guards positioned only at the top, leaving the bottom unprotected and allowing residents to contact the heat source, which exceeds 120°F.”

“A portable space heater in the dining room on the first floor was placed between dining room tables close to a resident walker, presenting a trip risk and making it uncomfortable for the resident to stand or sit.”

“Portable space heaters in a bedroom were obstructing the bedroom doorway and living room hallway, which led to the apartment's main entrance, blocking unobstructed egress routes.”

“Five portable space heaters were found in use in the facility: one at the main entrance, two in the dining room, and two in a bedroom. Portable space heaters are prohibited.”

“Two resident medical evaluations did not include all required components: one evaluation was missing medical information pertinent to diagnosis and treatment in case of an emergency and allergies; another was missing medical information pertinent to diagnosis and treatment in case of an emergency.”

“A training record for 'Administration of Prescription Toiletries' conducted on 9/27/23 was missing required documentation including the location of training, the training source, and the length of training in hours.”

“A tube of Colgate Baking Soda and Peroxide Whitening toothpaste labeled with poison control warnings was found unlocked, unattended, and accessible to resident #1. Not all residents in the home, including resident #1, were assessed as capable of safely recognizing and using poisonous materials.”

“Resident #2, who self-administers medications, stored medications in an unlocked drawer in his/her bedroom on 10/05/23 at 3:00pm, rather than in a locked, safe, and secure location as required.”

“Staff person B placed resident #1's medication on the bathroom counter where it remained unadministered. The staff member failed to complete required medication administration steps including placing the medication in a medication cup or the resident's hand, administering the medication as prescribed, and documenting the administration.”

“On 9/26/23 at 8:30pm, a medication for resident #1 was pre-poured in a disposable medication cup located in resident #3's bathroom more than 2 hours before the scheduled administration time. The resident was not aware of the medication being available.”

“Resident-home contracts for three residents were not signed by the residents as required.”

“The stopper in the bathroom sink in room 109 was broken and the sink was unable to drain.”

“An unlabeled, undated plastic container of salad was found in the refrigerator in the tavern on the third floor.”

“Two patio chairs and a patio table blocked egress from the home's Memory Care sunroom on 5/10/23 at 10:14 am.”

“Staff person A administered prescription medications including oral, topical, eye, nose and ear drop medications, insulin injections and epinephrine injections without completing required medication administration training as specified in § 2600.190.”