Morningside House of Exton.

“Staff person did not provide complete staffing records immediately upon request by a Department agent. Records were not provided until the following day.”

“Two resident-home contracts were not signed by the residents, and there was no indication the residents were given the opportunity to sign.”

“Direct care staff person B began providing unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test.”

“Unlabeled, undated ketchup, mustard, and chocolate syrup were found in the main kitchen refrigerator.”

“A medication was found in the home's medication cart; however, the home does not have a current order from the physician for this medication.”

“A loose white oblong unidentified pill was found in the home's memory care medication cart. This is a repeat violation.”

“A glucometer reading was documented on a resident's medication administration record that was not found in the resident's glucometer, indicating a discrepancy in medication storage and documentation procedures.”

“A resident prescribed specific times for glucometer readings and insulin dosing based on blood sugar levels did not receive documented readings at the prescribed times, and documentation indicated a reading that was not found in the resident's glucometer.”

“Staff training records were incomplete and inaccurate, missing required documentation of training length, source, and content. One training record included an undated staff signature page identical to another training, and a training date was obscured by whiteout.”

“Resident support plans were incomplete and did not document medical, dental, vision, hearing, mental health or other behavioral care services. Two residents' support plan sections for physical, mental, cognitive, behavioral, social and recreational needs were left blank despite assessments indicating these needs.”

“The Department's residents' rights poster was not posted in a conspicuous and public place in the Memory Care Unit.”

“Two half-full, uncovered, unattended trash cans were observed in the main kitchen on July 1, 2025 at 10:44 a.m., which do not prevent the penetration of insects and rodents.”

“The toilet paper holder in room 219's restroom was broken and not in good repair.”

“The lamp in bedroom 306 does not have a working light bulb that can be turned on or off at the bedside.”

“The current week's menu or one week in advance menu, stating the specific food being served at each meal, was not posted in a conspicuous and public place in the Memory Care Unit. Only the daily menu for July 1st was posted.”

“Resident #1 was denied insulin administration despite documented long-standing insulin dependency and elevated blood glucose readings ranging from 187-300 mg/dL over multiple days. The facility forced the resident to use the house physician rather than their chosen primary care physician as a condition of admission, and the house physician's DME omitted the resident's insulin requirement. The resident was subsequently hospitalized with hyperglycemia, hypernatremia, and moderate malnutrition, and passed away on 12/21/24.”

“Staff A and Staff Person B required Resident #1 to use the home's physician as a condition of admission, violating the resident's right to choose their own healthcare provider without limitation by the home.”

“Staff person B did not receive required annual training in fire safety completed by a fire safety expert, emergency preparedness procedures and recognition/response to crises, and resident rights during training year 2024.”

“During multiple shifts on the inspection date, 35 residents were present in the home with no staff persons certified in first aid, obstructed airway techniques, and CPR, violating the requirement for at least one certified staff person per 50 residents at all times.”

“Staff person A did not receive required orientation on fire safety and emergency preparedness topics on their first day of work, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher location and use, smoke detectors/fire alarms, and emergency notification procedures.”

“Multiple poisonous materials were unlocked, unattended, and accessible to residents: Colgate toothpaste in two rooms and Listerine mouthwash in one room; Vaseline in one room; and Shea Hand Sanitizer in the Memory Care Coordinator's office. Not all residents were assessed as capable of recognizing and using these poisons safely.”

“Sanitary conditions were not maintained: a used disposable glove was on the bathroom floor and a bag of trash was on the floor inside the entrance door of a resident room.”

“Unlabeled, undated, and uncovered bananas were on a tray, and an unlabeled, undated, partially melted and re-frozen bowl of ice cream was in the Memory Care freezer, violating food labeling, dating, and covering requirements.”

“Two staff members (Staff Person A and Staff Person B) did not receive required annual training in emergency preparedness, fire safety, and resident rights during the training year.”

“The Influenza Awareness Act poster was not posted in a public and conspicuous place in the residence. The poster was temporarily relocated during an ongoing renovation project.”

“The Department's resident's rights poster was not posted in a conspicuous and public place in the home. The poster was temporarily relocated during an ongoing renovation project.”

“The telephone numbers of the Department's personal care home regional office, local ombudsman or protective services unit in the area agency on aging, Disability Rights Pennsylvania, local law enforcement agency, Commonwealth Information Center, and personal care home complaint hotline were not posted in large print in a conspicuous and public place in the home.”

“The home's staff training plan did not include the name, position, and duties of each direct care staff person and the dates of the scheduled training for each staff person for the upcoming year.”

“Electric outlets on the 1st and 2nd floors were uncovered, exposing electrical wires. Wall lamps on the 2nd floor were exposing the lightbulb and electric wire. A smoke detector was covered in plastic on the 2nd floor. These hazards resulted from an ongoing painting and remodeling project.”

“The weekly menu was not prominently displayed in the memory care unit or in a public and conspicuous place throughout the home. The menu posting was temporarily relocated during an ongoing renovation project.”

“A resident who self-administers medications had several unlocked, unattended medications stored in an open drawer in their bedroom, including tablets and capsules. Medications stored in the resident's room must be kept locked in a safe and secure location to protect against contamination, spillage, and theft.”

“Changes in medication must be made in writing by the prescriber or, in emergencies, an alternate prescriber. The documentation of a medication change was incomplete or not properly recorded as required.”

“The home failed to immediately notify the resident's designated person when resident #1 eloped from the Secured Dementia Care Unit. The resident was absent from the unit around 3:30 PM but family was not notified immediately.”

“Resident #1 eloped from the Secured Dementia Care Unit unnoticed and walked approximately 3 miles down a busy highway, remaining unaccounted for about 2 hours. The resident was not physically checked at shift change as required, and hourly checks were not performed despite needing regular supervision due to cognitive impairment and lack of safety awareness. The home failed to report the incident to police or family immediately.”

“Crest toothpaste with a warning label was found unlocked, unattended, and accessible to residents in a shared bathroom. The label indicated that if more than used for brushing was accidentally swallowed, medical help or Poison Control should be contacted. Not all residents were assessed as capable of safely recognizing and using poisons.”

“A pink shower puff was observed in a shower shared by two residents without any label identifying which resident it belonged to, violating requirements that towels and washcloths be in the possession of the resident or properly identified.”

“An incident report for missing money from a resident's room was submitted without the date of the incident. Additionally, incident reports for two other residents regarding missing money were not reported to the Department within the required 24-hour timeframe.”

“Three residents experienced missing money from their rooms. The home does not provide an adequate system for safeguarding residents' money and property.”

“A resident's medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency, which is required within 60 days prior to admission or within 30 days after admission.”

“Two residents participated in the development of their support plans but did not sign the support plans as required. Individuals who participate in support plan development must sign and date the plan.”

“Resident records are missing required documentation: one resident's record does not include incident reports; two residents' records do not include Social Security numbers; one resident's record does not include Social Security number or race.”

“The home failed to immediately notify the resident's designated person when resident #1 eloped from the Secured Dementia Care Unit. The resident was absent from the unit around 3:30 PM but family was not notified immediately.”

“Resident #1 eloped from the Secured Dementia Care Unit unnoticed and walked approximately 3 miles down a busy highway, remaining unaccounted for about 2 hours. The resident was not physically checked at shift change as required, and hourly checks were not performed despite needing regular supervision due to cognitive impairment and lack of safety awareness. The home failed to report the incident to police or family immediately.”

“Crest toothpaste with a warning label was found unlocked, unattended, and accessible to residents in a shared bathroom. The label indicated that if more than used for brushing was accidentally swallowed, medical help or Poison Control should be contacted. Not all residents were assessed as capable of safely recognizing and using poisons.”

“A pink shower puff was observed in a shower shared by two residents without any label identifying which resident it belonged to, violating requirements that towels and washcloths be in the possession of the resident or properly identified.”