Columbia Cottage - Linglestown.

“Resident requiring assistance with toileting every 2 hours per assessment and support plan did not receive this assistance on multiple occasions, with gaps ranging from 3.75 to 4.83 hours between toileting times. Additionally, a resident requiring two-person assist with transfers was transferred by only one staff member.”

“One resident pushed another resident, causing the victim to fall to the ground and sustain two abrasions on the underside of the left forearm, each approximately 1.5 to 2 inches long.”

“Multiple poisonous materials were observed unlocked, unattended, and accessible to residents in public bathrooms of the Special Care Unit, including baby powder with caution labels, Lysol disinfectant spray, zinc oxide paste, and petroleum jelly. Residents in the SCU have not been assessed as capable of safely using or avoiding these poisons.”

“Staff members indicated that loose pills would be disposed of in a sharps container, which is not an approved method of destroying medications according to Department of Environmental Protection and Federal and State regulations.”

“A resident prescribed medication to be given at 3:00 AM did not receive the medication on one date because it was not available in the residence, and on another date because the resident was sleeping. A second resident prescribed to inhale one puff of medication daily was not administered as prescribed.”

“An unlabeled, undated, uncovered stainless steel container of fruit and a tray of unlabeled cupcakes were found in kitchenette refrigerators, violating food storage and labeling requirements.”

“Resident #1's most recent medical evaluation was not completed annually as required.”

“Pink sticky substance was observed in the freezer of a kitchenette, and the floor was very sticky when walked on, indicating unsanitary conditions.”

“Two open windows with no screens were observed in two separate kitchenettes, violating the requirement that windows must be securely screened when open.”

“A freezer door handle was observed to be broken off and removed in one of the kitchenettes, creating a hazard.”

“Resident #3's Dexcom blood glucose readings did not match the medication administration record (MAR) on multiple dates (6/1 through 6/11/2025), indicating improper documentation and storage procedures for medical equipment.”

“Resident's enabler bar attached to bed had an improperly applied cover with large openings (6 inches by 6 inches on one side and 11 inches by 6 inches on the other) and a ripped cover, creating potential entrapment hazards.”

“Staff Member C administered 10 medications to resident in morning and failed to ensure resident took all medications before documenting administration. Specific medications not ingested could not be determined due to altered state of some medications.”

“Discontinued medication (Ativan 0.5mg) was in the residence's memory care medication cart despite being discontinued.”

“Unopened and unused medication was stored at room temperature in medication cart instead of being refrigerated as required by manufacturer's instructions.”

“Multiple medication labeling deficiencies: two residents' topical medications lacked required dosage, administration instructions, and prescriber information; one resident's medication was in ziplock bag without proper labeling; one resident's medication label showed incorrect administration times (8AM, 2PM, 8PM) versus actual administration times (6AM, 2PM, 10PM).”

“Resident #2 kicked Resident #1 twice on an unspecified date. The incident was observed by Staff member A and reported via electronic incident report on 4/17/24. However, at the time of the 6/11/24 inspection, this suspected abuse had not been reported to the local Area Agency on Aging as required.”

“Resident #2 kicked Resident #1 twice. The incident was observed by Staff member A and reported via electronic incident report on 4/17/24. At the time of the 6/11/24 inspection, this allegation of abuse had not been reported to the Department within 24 hours as required.”

“On 6/11/24, poisonous materials (Dermarite Renew skin repair cream and Calmoseptine ointment, both with poison control labels) were observed in an unlocked cabinet in Resident #5's bathroom. Resident #5 resides in the secured dementia care unit and requires poisonous materials to be locked.”

“On 6/11/24 at 10:10 AM, the hot water temperature in Resident #5's bathroom measured 125.7 degrees Fahrenheit, exceeding the maximum allowable temperature of 120°F.”

“On 6/10/24 at approximately 10:00 AM, a reclining chair in the 100's dining room had its back detached from the left side. Staff reported the chair had been broken and in need of disposal for several weeks, but it remained in an accessible location to residents.”

“On 6/11/24, the temperature in the 300's neighborhood kitchenette refrigerator was 45 degrees Fahrenheit at 10:20 AM and remained 45 degrees Fahrenheit at 3:00 PM, exceeding the maximum allowable temperature of 40°F for food requiring refrigeration.”

“A laptop computer sitting on top of the medication cart in the 300 hall was found unlocked and unattended, with electronic medical records for residents unlocked and accessible to unauthorized persons.”

“The medicine cart in the 300 hall was found unlocked, unattended, and accessible. Although the lock appeared engaged, drawers 3-6 contained various resident medications and were able to be opened easily without force.”