Arden Courts (warminster).

“The support plan for a resident did not indicate the behavioral or cognitive need and degree for judgment, understanding instructions, or the ability to use and avoid poisonous materials, as required by support plan needs elements.”

“No toilet paper was provided for the toilet in the hallway bathroom in Berry Ridge hall.”

“One loose red round pill was observed in the Dockside medication cart and one loose white oblong pill was observed in the Berry Ridge medication cart. Additionally, medication blister cards were observed with punctured slots on the back, not stored in accordance with manufacturer's instructions.”

“A tube of zinc oxide paste skin protectant was observed in the Cloverdale medication cart and was not labeled with the resident's name.”

“A resident's initial assessment did not document a dietary need for no added sodium, despite the resident's most recent medical evaluation indicating this special diet requirement.”

“Head and Shoulders Shampoo with poison control warning was found unlocked, unattended, and accessible to a resident. The resident had not been assessed as capable of safely recognizing and using poisonous materials.”

“An unopened medication bottle was found in the medication cart that should have been refrigerated per manufacturer's instructions. An undated, opened medication bottle was found in the medication cart stored incorrectly and past its 30-day discard date.”

“Two residents' medications had pharmacy labels with inaccurate dosage and administration instructions that did not match the physician's orders. One label indicated morning administration when the order specified bedtime; another indicated bedtime when the order specified morning.”

“Staff Member B physically abused a resident by shaking their head, swatting them with a blanket, physically restraining them against a wall, forcefully pushing them with a wheelchair causing them to fall, making kicking motions over the resident, and leaving the resident on the ground in the hallway. This is a repeat violation.”

“Staff Member B did not receive required first-day fire safety and emergency preparedness orientation including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and telephone use for emergency services.”

“Staff Member B did not complete required 40-hour orientation training on the Emergency Medical Plan within 40 scheduled working hours of employment.”

“Prescription and OTC medications were found with punctured blister foils while still containing medication, exposing them to contamination and improper sanitation. This is a repeat violation.”

“OTC medications were found in the medication cart without labels identifying which resident they belonged to.”

“A staff member attempted to defraud a resident by initiating a fraudulent transaction using the resident's bank account information, which was accessible in the resident's bedroom. The staff member created a Zeffy fundraising account and processed a test transaction (one cent deposit and withdrawal) from the resident's account before subsequently resigning.”

“A doorknob to a resident bedroom was loose and protruding from the inside of the resident's bedroom door, creating a hazard.”

“The narcotic log documenting administration of Lorazepam medication was confusing and illegible, with entries partly or fully crossed out on nine different lines, making it impossible to accurately track medication administration, wastage, and inventory counts.”

“Staff persons A and B completed CPR training with National CPR Foundation, which is not certified as a trainer by a hospital or other recognized health care organization. Current first aid training and CPR certification must be provided by an approved training source.”

“Fire extinguishers in the Harvest Glen kitchen (serviced Nov 2024) and the hallway outside the main kitchen (serviced Jan 2024) were undercharged and not operable.”

“Fire extinguishers in the Berry Ridge kitchen (not inspected since Feb 2024), Cloverdale kitchen (not inspected since Jan 2024), and the hallway outside the main kitchen (not inspected since Jan 2024) were not inspected annually by a fire safety expert.”

“An allegation of resident-to-resident abuse (a resident hitting another resident in the head) was not reported to the local Area Agency on Aging within the required timeframe. The incident occurred at 10:30 AM but was not reported to Area Agency on Aging until 11:00 AM.”

“An incident of resident-to-resident abuse was not reported to the Department's personal care home regional office within the required 24 hours. The incident occurred at 10:30 AM but was not reported to the Department until 11:30 AM.”

“A resident's most recent annual medical evaluation was not completed within the required annual timeframe. The resident has since expired, and the deficiency cannot be retroactively corrected.”

“Staff person A tied pantyhose from Resident 1's doorknob to an outside handrail, preventing the resident from leaving their room. The facility failed to report this incident to the Department within 24 hours as required.”

“Staff person A tied pantyhose from Resident 1's doorknob to an outside handrail, confining the resident to their room for approximately one hour. The resident was emotionally distressed and confused by this confinement. This is a repeat violation (prior violations on 10/23/23 and 3/28/24).”

“Staff person A tied pantyhose from Resident 1's doorknob to an outside handrail at 1:00 am, constituting a restraint that prevented the resident from leaving their room.”

“Staff person A tied pantyhose from Resident 1's doorknob to an outside handrail, blocking the egress route and impeding the resident's ability to exit the room.”

“Despite Resident 1's care plan requiring positive interventions and safe management techniques for a resident who wanders and has poor judgment, Staff person A confined the resident by tying pantyhose from the doorknob to an outside handrail instead of using appropriate supervision and redirection. This is a repeat violation (prior violations on 10/23/23 and 3/28/24).”

“Staff person A confined Resident 1 to their room by tying pantyhose from the doorknob to an outside handrail, constituting prohibited seclusion as the resident was physically prevented from leaving the room.”

“Criminal background check on file for Staff A, who was rehired after more than a year's absence, was dated 08/31/2022 and did not meet requirements for rehired employees.”

“Floor in resident room was wet with urine, creating a hazard. A resident slipped on the urine and fell during an interaction with staff over wet linens.”

“Resident was identified as a fall risk on 01/11/2024 due to unsteady gait, ambulatory dysfunction, and poor self-safety awareness, but a new medical evaluation was not completed despite a previous evaluation on 11/13/2023 that did not address body positioning and movement.”

“Staff A failed to use positive interventions with a resident known to be resistant to changing soiled clothes and bedding. When the resident refused to release wet bedding and raised a hand as if to hit staff, Staff A did not redirect or give the resident space, allowing the situation to escalate to violent behavior and a fall. This is a repeat violation from 10/23/2023.”

“Staff failed to prevent sexual contact between two residents in the memory care unit. Resident 2 was observed naked on top of Resident 1 in Resident 2's room during a 15-minute check. While both residents were reported to have consented and families approved, the facility's support for the sexual acts without proper safeguards constitutes failure to protect residents from abuse or mistreatment.”

“Staff Person A did not receive annual fire safety training completed by a fire safety expert or by a staff person trained by a fire safety expert during training year 2022, in violation of annual training content requirements.”

“Poisonous materials including toothpaste, deodorant, bar soap, bath salt, mouthwash, and shampoo with manufacturer labels warning to keep out of reach of children were unlocked, unattended, and accessible to Residents 3 and 4. Residents have not been assessed as capable of recognizing and using poisons safely.”

“Bathrooms in bedrooms 23, 24, 36, and 39 do not have an operable window or functioning ventilation fan. The exhaust fans are inoperable with no windows present.”

“Furniture and equipment were in disrepair: the bathroom sink in Room 36 was clogged and the bathroom sink faucet in Room 39 was broken with water leaking from the top of the faucet.”

“Resident 5 did not have any towels or other means of hand drying in his/her bathroom, violating the requirement that towels and washcloths be in the resident's possession in the living space.”

“Food was not stored in closed or sealed containers. Ice cream in an opened and unsealed box was found in the kitchen freezer of the garden unit.”

“The home's written emergency procedures do not include the contact information for each resident's designated person, as required.”