Elizabeth Seton Memory Care Center.

“Staff training records for direct care staff person A lack documented dates for completion of annual trainings during the training year.”

“Fire drill records document total evacuation times in minutes only, without including seconds as required.”

“A resident's medication pharmacy label indicated the medication was to be given as needed for restlessness/agitation, but the physician order specified it should be given as needed for anxiety.”

“Multiple residents' medication administration records for September 2025 are missing the initials of staff persons who administered medications at specified times, including tablets taken by mouth, topical applications, and supplements.”

“Staff person A forcefully pulled a resident's hand off a grab bar during toileting assistance, causing the resident and another staff member to lose balance. Staff person A continued pulling the resident from the toilet into a wheelchair, pushed the resident into the chair, and swore at the resident when asked why they were in a hurry and causing pain. This treatment violated the requirement that residents be treated with dignity and respect.”

“A resident reported that another resident pulled their hair and scratched them. This allegation of abuse was not reported in accordance with the Older Adult Protective Services Act.”

“An incident involving one resident pulling hair and scratching another resident was not reported to the Department within 24 hours.”

“Allegations of abuse involving physical restraint and rough handling of residents were not reported immediately in accordance with the Older Adult Protective Services Act. Multiple incidents occurred where staff person B physically restrained residents using body weight and limbs to prevent them from leaving chairs, and another incident where a resident reported being handled roughly during care.”

“Multiple incidents of alleged abuse were not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required. One incident was reported on 9/17/24, and others were not reported until 9/17/24, despite occurring in late August and early September 2024.”

“A resident was physically restrained by staff person B who sat on the arm of a chair and used body weight to lean over the resident to prevent them from standing up. The resident yelled, exhibited signs of anxiety and distress, and stated they could not believe what was happening. On two separate occasions between late August and early September 2024, staff person B used legs and arms to keep another resident in an armchair against their will.”

“Direct care staff person was hired without completion of a Pennsylvania State Police criminal background history check as required.”

“Ancillary staff person hired did not receive annual training in emergency preparedness procedures, recognition and response to crisis and emergency situations, resident rights, the Older Adult Protective Services Act, or falls and accident prevention during the 2023 annual training year.”

“Records of annual trainings completed during 2023 for multiple staff members did not include the dates the trainings were completed.”

“Poisonous materials were not stored in original, labeled containers with proper poison precaution labels. Multiple containers in the housekeeping storage room lacked poison labels, and one 3-gallon container was unlabeled.”

“Trash receptacles in kitchens and bathrooms were not kept covered to prevent insect and rodent penetration. An uncovered 55-gallon trash can in the dishwashing room and an uncovered trash can in the spa bathroom were observed.”

“Fire drills held during sleeping hours from December 2022 to February 2024 were conducted on the same shift and around the same time of day (6:22 a.m., 6:36 a.m., and 6:28 a.m.), failing to meet the requirement for different days, times, and varied circumstances.”

“A resident's prescription medication pharmacy label indicated the medication be administered three times daily, but the prescription was actually three times per day as needed for anxiety, creating a labeling discrepancy.”

“A resident's blood sugar testing strips were expired as of 1/31/24, indicating a failure to implement proper procedures for safe storage and maintenance of medical equipment.”

“A resident's assessment of care needs did not address the resident care needs for bed alarms and fall mats currently installed at the resident's bedside.”