Arden Courts (king of Prussia).

“Direct care staff person B completed 0 hours of annual training in training year 2024, failing to meet the 12-hour annual training requirement.”

“The resident-home contract for resident #1 was not signed by the resident as required.”

“Resident #2 did not receive medication management at 2:00 pm as required by the support plan due to lack of available direct care staffing in the home.”

“From 11pm-7am on 7/26/2025, 60 residents were present with only two staff certified in CPR and one staff certified in First Aid, failing to meet the requirement of at least one staff person for every 50 residents trained in first aid and CPR.”

“Staff person A was trained in CPR by National CPR Foundation, which is not certified as a trainer by a hospital or other recognized health care organization. This is a repeat violation from 9/30/2024.”

“Direct care staff person B did not receive required training topics in 2024, including medication self-administration training, instruction on meeting resident needs, care for residents with dementia and cognitive impairments, infection control and hygiene, personal care service needs, safe management techniques, and care for residents with mental illness or intellectual disability.”

“Direct care staff person A received only 4 hours of annual training in training year 2024, which is below the required 12 hours of annual training relating to their job duties.”

“Direct care staff person A did not receive required training topics during training year 2024, including medication self-administration training, instruction on meeting resident needs, care for residents with dementia, infection control and hygiene, personal care service needs, safe management techniques, and care for residents with mental illness or intellectual disability.”

“Staff person A did not receive required annual training during training year 2024 in fire safety (by a fire safety expert or trained staff), emergency preparedness procedures, resident rights, the Older Adult Protective Services Act, and falls and accident prevention.”

“Poisonous materials with manufacturer labels warning to seek medical help or contact Poison Control if ingested were found unlocked, unattended, and accessible to residents in bathroom cabinets, on bureaus, and in kitchenette cabinets. This is a repeat violation at a secured dementia care unit where residents cannot safely recognize and use poisons.”

“Direct care staff person A received only 7 hours of annual training in 2024 instead of the required 12 hours. Direct care staff person B received 0 hours of annual training in 2024.”

“Cleaner with bleach with hazardous labeling and a 3/4 full bottle of Pedialyte were stored in a cabinet above the microwave in the Dockside Kitchen, violating the requirement to store poisonous materials separately from food and food preparation surfaces.”

“Multiple poisonous materials including Aquaphor, toothpaste, soap, bleach, and cleaning products were found unlocked, unattended, and accessible to residents in various rooms. Not all residents had been assessed as capable of safely recognizing and using poisonous materials. This is a repeat violation.”

“Multiple sanitary condition violations were found including: overwhelming urine smell from HVAC unit in a room; blood and feces on toilet seat and floor in a bathroom; used adult incontinence brief on floor; dried blood on walls and door; spills in freezer and cabinet in Dockside kitchen; strong urine odor in halls and bathrooms with urine caked on toilets and floors. This is a repeat violation.”

“Medications not listed on the resident's current order were kept in the home's medicine cabinet. The medications were from the resident's home supply provided by family and were never used, but were inappropriately stored.”

“A pharmacy label for a resident's medication read '1 tab every 12 hours' but the resident was prescribed to take the medication twice a day, requiring a direction change sticker. The medication was from the resident's home supply provided by family and was never used in the home.”

“A bottle of OTC/CAM medication belonging to a resident was not labeled with the resident's name. The medication was from the resident's home supply provided by family and was never used in the home.”

“A resident's medication administration record did not include the initials of the staff member who administered the resident's 08:00 AM medications on the day the resident was sent to the hospital at approximately 10:30 AM.”

“A resident's 08:00 PM prescribed medications were not administered to the resident on the scheduled date.”

“Food stored in medication cart was opened and unsealed. Pudding in the plum medication cart was not properly stored in a closed or sealed container.”

“Discontinued medication was present in the medication cart. A medication prescribed for a resident was found in the plum cart despite being discontinued.”

“Medications were not stored in an organized manner under proper conditions. Two loose pills were found in the plum cart and two unlabeled, unrefrigerated syringes with an expired date were found on the cart.”

“Medications for a permanently discharged resident were not removed from the medication cart. Prescribed cream and patches for a resident who discharged from the home were present on the plum cart.”

“Pharmacy labels on medications found in the medication cart were missing required information including resident name, prescription issue date, dosage and administration instructions, and prescriber name and title. Two unlabeled syringes lacked all required pharmacy label elements.”

“The home did not have a background check on file for a Hospice nurse who provided care to a resident.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.”

“Staff person A's CPR certification was issued by Life Training Resources, which is not certified as a trainer by a hospital and is not a recognized health care organization.”

“Discontinued or comfort medications were present at the nurses station and were not properly disposed of according to DEP and Federal and State regulations.”

“Medication administration records did not include special precautions (refrigeration required) for one resident's medication and did not indicate diagnosis or purpose for another resident's medication. This is a repeated violation.”

“A copy of Chapter 2600 Regulations was not posted in a conspicuous and public place in the home.”

“Hourly check and incontinence logs with resident information were unlocked, unattended, and accessible in the Plum Neighborhood kitchenette on top of the refrigerator. This is a repeat violation.”

“Video cameras recording footage at the entrances and exits of the home had no sign posted to indicate video recording on site.”

“The shed door inside the courtyard for the memory care home was unlocked and contained poisonous items including ice melt, salt buckets, and Round Up herbicide. Residents are not all assessed as capable of safely using or avoiding poisons.”

“A resident was physically abused by staff member A during an incident in the kitchen. The staff member pushed the resident, threw an elbow striking the resident in the face, and swung keys at the resident, resulting in multiple injuries including skin tears, bruising, facial swelling, and rib trauma. The resident required emergency department evaluation.”

“Medication administration records were not properly initialed by staff members at the time medications were administered. Multiple instances were documented where staff failed to initial medication administration records for residents' prescribed medications including Certravite Senior and other medications administered at various times throughout the day.”

“An opened bottle of eye drops was stored in the medication cart without an open/discard after date. According to manufacturer's instructions, the eye drop should be discarded 4 weeks after opening.”

“Missing medication documentation and discrepancies in controlled medication logs. Disposal of medication by overnight shift was not noted on controlled medication log as required. One pill was missing from controlled medication record with no explanation for the discrepancy.”

“Medication Administration Records (MARs) for two residents did not indicate the diagnosis for prescribed medications as required.”

“Medications were documented as administered on MARs with staff initials but were not actually administered or signed out on controlled medication records at the time of administration.”

“Medications prescribed by the physician were not administered to residents as directed. One resident did not receive a prescribed once daily medication on specified date, and another resident did not receive prescribed three-times-daily medication on specified dates.”

“Resident medical evaluation dated 11/16/2023 did not include medical information pertinent to diagnosis and treatment in case of emergency, immunization history, and body positioning and movement stimulation for residents, if appropriate.”

“Resident's record does not include a record of incident reports for the individual resident.”

“A photograph and information identifying a resident as an elopement risk was posted outside the memory care unit, violating resident record confidentiality requirements.”

“A resident eloped from the secured exterior courtyard by climbing over a 7-foot vinyl fence while staff assigned to that area was unaware of the resident's absence. The resident was found 1.5 miles away at King of Prussia Mall by mall security.”

“Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required for direct care staff qualifications.”

“Directions for operating the home's key-locking mechanism were not conspicuously posted near the door to the Secure Dementia Care Unit. Interior and exterior door codes had not been updated with new codes.”

“Staff member removed pills from container and entered initials on medication administration record (MAR) before administering pills to resident. Resident initially refused pills and staff had to return cup to medication cart.”

“Medication cart for the home's Blue Hallway was unlocked, unattended, and accessible on the inspection date.”

“Discontinued medications (Allergy Relief prescribed for two residents) were present in medication cart and not listed on current Medication Administration Records. One medication that expired was still present in the medication cart.”

“Controlled medication log for a resident prescribed medication every 6 hours as needed does not explain missing pills during a specified time period. Another resident had no controlled medication log established.”

“Resident's November MAR does not indicate the diagnoses or purposes of multiple prescribed medications. Another resident's MAR reads incorrect dosage form description (delayed release) for prescribed medication. This is a repeated violation from 05/22/2023.”

“Directions for operating the home's locking mechanism are not conspicuously posted near the door to the Secure Dementia Care Unit. Interior and exterior doors throughout the home were not updated with the new code.”

“A photograph and information identifying resident #1 as an elopement risk was posted outside the memory care unit, violating resident record confidentiality requirements.”

“Resident #1 eloped from the secured exterior courtyard by climbing over a 7-foot vinyl fence and was found 1.5 miles away at King of Prussia Mall. Staff assigned to the area were unaware of the resident's absence. Additionally, on 10/17/2023, staff were observed not performing scheduled hourly checks, with direct care duties taking priority over safety checks.”

“Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.”