Serenity Care Kingston.

“Snow and ice obstructions were blocking exit doors in three locations: the 300 hallway (8-inch accumulation), the Secured Dementia Dining Room (8-inch accumulation), and the 400 hallway (8-inch accumulation) at the time of inspection.”

“Medication administration record for Resident 4 on 1/1/2026 at 12:05 p.m. documented 35 units of NovoLog Flexpen administered for a blood glucose reading of 324, which did not match the sliding scale order (>301: 12 units). Staff interviews indicated the resident received 12 units, indicating a documentation error.”

“Resident 4's sliding scale insulin order required notification of the doctor if blood glucose reading exceeded 301. On 1/1/2026, a reading of 324 was documented but the doctor was not notified as prescribed. This was a repeat violation from 04/18/2025.”

“Initial resident assessments for Resident 1 and Resident 5 did not document the residents' need for Hospice agency services and Home Health Agency providing catheter care.”

“A resident's bedside mobility device was not attached to the bed frame and could be easily moved, posing a possible risk of injury or entrapment.”

“A resident admitted to the Secure Dementia Care Unit (SDCU) on 10/4/25 did not have an initial support plan completed within 72 hours; the plan was completed on 10/9/25.”

“Employee A handled a resident roughly and struck the resident in the back with a closed fist while holding a washcloth during a shower. This constitutes physical abuse and mistreatment of a resident.”

“A grey wheeled utility cart blocked egress from the dining room exit door to the outside parking lot, obstructing an emergency exit route.”

“During a fire drill conducted on 5/31/25 at 10:15pm, residents refused to evacuate the building during the fire drill, failing to proceed to the designated meeting place away from the building or within the fire-safe area.”

“A resident was admitted to the Secure Dementia Care Unit (SDCU) on 5/9/25, but the required written cognitive preadmission screening completed in collaboration with a physician or geriatric assessment team was not completed within 72 hours prior to admission.”

“Residents prescribed daily blood glucose readings at 4:00 P.M. were not administered their glucose checks at the scheduled time. Additionally, a resident prescribed 0.5mg tablet at bedtime received an incorrect dosage of 1mg instead.”

“Resident #1 receiving hospice care was not evacuated during fire drills conducted from October 2024 through March 2025 but lacked written certification from a physician that the resident is actively dying and may suffer bodily injury or hastened death from fire drill participation.”

“There is no statement of informed consent from Resident #1 or the resident's power of attorney regarding the resident not evacuating during fire drills, despite the resident not being evacuated during fire drills conducted from October 2024 to March 2025.”

“During fire drills conducted from October 2024 through March 2025, the designated person at the home with advance knowledge of the fire drill did not go to Resident #1's room to notify the resident and staff that it was a fire drill and the resident was not to be evacuated. Staff interviewed did not confirm this notification occurred.”

“Resident #1 receiving hospice services was not evacuated during fire drills conducted from October 2024 through March 2025 and did not meet the provisions of 55 Pa Code § 2600.29.a.b(4), therefore the resident should have been evacuated but was not.”

“Resident #1's assessment and support plan were not kept current and did not specify the requirements relating to hospice care evacuation procedures for the specific resident.”

“Staff Person A used Resident #1's glucometer to test Resident #2's blood glucose level, creating a cross-contamination and infection control risk.”

“Medication room door was unlocked and unattended with E-MAR screen open displaying resident information. A blister pack of Acetaminophen 325 mg prescribed for Resident #3 was left on top of an unattended medication cart in the hallway outside the Administrator's office, exposing resident confidential information.”

“Resident #5 grabbed the back of Resident #6's sweater and hit them in the back in the memory care unit. Both residents were immediately separated and assessed with no injuries observed.”

“Approximately 10 cigarette butts were observed on the pavement between both dumpsters outside of the designated smoking area, indicating employees smoking in a nonsmoking area.”

“Medication room door and medication cart were unlocked and unattended. A blister pack of Acetaminophen 325 mg prescribed for Resident #3 was left on top of an unattended medication cart in the hallway outside the Administrator's office.”

“Medication label for Metoprolol Succ ER 100 mg tablets prescribed for Resident #4 indicated ½ tablet daily, but the Medication Administration Record indicated 1 tablet (50mg) daily, creating a discrepancy.”

“Resident #2 is prescribed polyethylene glycol 3350 powder PRN for constipation, but the medication was not on hand. This is a repeat violation from 6/28/23.”

“A resident used profane language against another resident in the Activity room, including telling them to 'shut up,' violating the requirement that residents be treated with dignity and respect.”

“A resident used profane language against another resident in the Activity room, telling them to 'shut up,' violating the requirement that residents be treated with dignity and respect.”

“A direct care employee pushed a resident in the chest into their room and held the door shut while the resident attempted to exit, while yelling at the resident. The resident sustained a skin tear and bruising on their right arm during this physical struggle.”

“A direct care employee pushed a resident into their bedroom and then held the door shut forcibly, preventing the resident from leaving the room despite their efforts to exit. This action constitutes seclusion, which is a prohibited procedure.”

“A direct care employee did not complete first day fire safety orientation training components for smoke detectors/fire alarms and telephone use/notification to emergency services until August 6, 2023, one day after hire on August 5, 2023.”

“Resident #2 has a preadmission screening form that did not indicate the home was able to meet the resident's needs in the Personal Care section of the home.”

“Resident #3 was admitted to the home's Secure Dementia Care Unit. The assessment portion of the Resident Assessment and Support Plan was completed, but the Support Plan portion was not completed within 72 hours of admission.”

“Resident #1's medical evaluation did not include the physician's license number.”

“Resident #3's PRN medications were administered but staff did not document the effectiveness of the medications. Resident #4's MAR entries for multiple medications were not initialed as being administered. Resident #5's MAR was not initialed and did not document vital parameters (pulse rate) or indicate if medication was held due to low pulse rate.”

“Resident #5's prescribed medication was not documented on the MAR with the resident's pulse rate and did not indicate whether the medication was being held due to low pulse rate, failing to follow the prescriber's orders.”

“Resident #1 began physical therapy services but the resident's assessment and support plan were not updated to indicate the change in care or therapy services started.”

“Resident #2 was admitted to the secured dementia care unit but the required cognitive preadmission screening was completed 3 days after admission instead of within 72 hours prior to admission.”

“Resident #2's record did not contain documentation that the resident and the resident's responsible party did not object to the resident's admission or transfer to the secured dementia care unit.”

“Resident #2 was admitted to the secured dementia care unit but the required support plan was not developed within 72 hours prior to or after admission.”