Serenity Gardens at Mount Carmel.

“Resident prescribed medications were placed in an unsecured tote bag in the facility's vehicle for transport to another facility. A discrepancy was discovered when the receiving facility reported receiving only 12 pills instead of 24 pills. The facility lacked a policy and procedure for transporting medications to another facility that addresses responsible parties, accountability, secured packaging, and documentation including signature, time, date, and receiver information.”

“The home failed to report an abuse allegation by a staff person against 4 residents to the Department within the required 24-hour timeframe.”

“At approximately 10:55 a.m., there was no thermometer in the freezer in the memory care kitchenette. Food requiring refrigeration shall be stored at or below 40°F and frozen food at or below 0°F with thermometers required in refrigerators and freezers.”

“At 11:02 a.m., there were 2 piles of lint with an approximate diameter of 2 inches each observed behind the dryer in the laundry room near a heat source. This is a repeat violation.”

“Fire drill records indicated that all residents were evacuated during fire drills; however, staff interviews stated that Resident J was not evacuated during these fire drills. A written fire drill record must include the date, time, evacuation duration, exit route used, number of residents and staff, and problems encountered. This is a repeat violation.”

“Resident was not evacuated to a fire safe area during fire drills conducted during the inspection period. Residents shall evacuate to a designated meeting place away from the building or within the fire-safe area during each fire drill.”

“Resident's medical evaluation did not have the box selected stating that the resident's needs can be safely met at a personal care home in the Medical Professional Information section. A resident shall have a medical evaluation at least annually.”

“At 10:51 a.m., there were 6 cigarette butts observed on the ground in the smoking area. A home that permits smoking must develop and implement written fire safety policy and procedures.”

“Resident self-administers medications and stores medications in their room in an unlocked drawer by the chair. The resident stated they do not lock the door when leaving the room. Medications stored in a resident's room for self-administration shall be kept locked in a safe and secure location.”

“A resident was admitted to the secured dementia care unit without a required written cognitive preadmission screening completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission. The resident was initially admitted as a personal care resident, found outside at night, and then permanently moved to the secured unit without the proper screening documentation.”

“Sleeping hours fire drills are routinely held between 5am and 6am, making them predictable. Fire drills must be held on different days and times, not routinely at predictable times.”

“The 55 PA Code Chapter 2600 regulations were not posted in a public conspicuous area of the home.”

“An unattended cleaning cart was located in the home's Secured Dementia Care Unit (SDCU) with a bucket of blue liquid (cleaning solution). The residents on the SDCU are not assessed to safely handle and identify poisonous materials.”

“Resident #2 did not have the required emergency telephone numbers posted by the resident's outgoing landline telephone in the resident's bedroom.”

“Several small pieces of broken glass were located near the home's dumpster.”

“A yellow and black cloth barrier was pulled across the entrance to the home's dining room, blocking egress to the emergency exit. The emergency exit door had two confusing paper signs reading 'DO NOT USE' and 'Fire Exit Only – This Door is not to be used as an Exit,' which may confuse individuals during evacuation. This was a repeat violation from 2/8/24.”

“Combustible and flammable materials (plastic Rubbermaid garbage can and industrial buffing pads) were located directly behind natural gas hot water heaters in the mechanical room, creating a potential fire hazard.”

“The fire drill record for 7/12/24 at 2:07 does not indicate if the drill was conducted in the AM or PM.”

“Resident #1 has an order for a medication to be applied 2x a week that was not available. Resident #2 has a PRN order for a medication 3x a day (description incomplete in source document).”

“Direct care staff person B, hired on an unspecified date, did not complete and pass the Department-approved direct care training course and competency test upon hire and before working with residents unsupervised.”

“Residents in rooms 302 and 307 did not have an operable lamp or other source of lighting that could be turned on at bedside.”

“Room 302 is a shared room. The bathroom had 1 bar of soap located on the sink that was not labeled or in a labeled container.”

“Located in the kitchen's can storage area were 2 dented cans (mushrooms and apricots) that may not be used per regulations.”

“Ivy Lane has a courtyard with a code-locked fence. After a recent snowstorm, snow was not removed from behind the gate, which blocked immediate egress in the event of an emergency.”

“A spray medication was unlocked, unattended, and accessible in resident #1's room. Additionally, during a medication cart audit, Staff A left the medication cart unattended numerous times while attending to residents or retrieving medications, leaving medications unattended on top of the cart.”

“Resident #1's medication administration record and pill pack contained conflicting dosage instructions. Additionally, a tube of desitin was found in the medicine cart without a pharmacy label or resident name, indicating which resident it belonged to.”

“The exit door located outside of the administrator's office required excessive force to open, preventing immediate egress in the event of an emergency.”

“The exterior grounds had a 12"x12" cutout in the cement near the outside door of the Ivy Lane courtyard (secured unit) filled with wood that had sunk approximately 1 inch on one side, creating a tripping hazard.”

“A fire drill conducted on 6/26/23 showed 56 residents in the home with only 52 evacuated. While 1 hospice resident had proper documentation for non-evacuation, 3 other residents who did not evacuate were not accounted for in the records.”