Magnolias of Lancaster.

“An unlicensed staff member administered a subcutaneous injection to a resident without proper authorization. The facility does not have a waiver permitting unlicensed direct care staff to administer medications subcutaneously.”

“A resident's medical evaluation did not include special health or dietary needs and did not indicate if the facility could safely meet the resident's needs or if services should be provided elsewhere.”

“The home failed to contact emergency services in a timely manner when two residents displayed serious medical symptoms including slurred speech, drooping, numbness in legs, and vital sign abnormalities. In one instance, the resident was not seen by a physician until 2:40 PM; in another, ambulance was not called until 1:47 PM despite symptoms observed earlier in the day.”

“The home documented that a resident self-administered all medications; however, two cups containing partially disintegrated pills were found on the resident's dresser, indicating the resident did not consume the prescribed medications and the home failed to complete all steps in the medication administration process to ensure medication consumption.”

“The date and time of medication administration were not recorded at the time a prescribed subcutaneous injection was administered.”

“Two incidents of suspected resident abuse were not reported to the local Area Agency on Aging as required. On one date at approximately 6:20pm, a resident punched another resident in the abdomen (observed by staff). On another date at approximately 10:42pm, a resident threw a drink at another resident, grabbed them by the neck, and hit them on the back of the head.”

“An incident occurring at approximately 10:42pm where a resident threw a drink at another resident, grabbed them by the neck, and hit them on the back of the head was not reported to the Department within 24 hours as required.”

“Four separate incidents of resident abuse occurred: (1) a resident punched another resident in the abdomen at approximately 6:20pm; (2) a resident threw a drink at another resident, grabbed them by the neck, and hit them on the back of the head at approximately 10:42pm; (3) a resident grabbed another resident's arm while aggressively attempting to put hand down the back of the shirt at approximately 3:22pm; and (4) a resident grabbed the private area of another resident at approximately 3:25pm. This is a repeated violation from prior inspections.”

“The bathroom across from the Dogwood neighborhood kitchenette did not have an operable window or ventilation fan.”

“A resident's bed did not have a pillow and sheets.”

“There was no thermometer in the small white freezer chest in the main kitchen.”

“A resident did not have access to a source of light that can be turned on/off at bedside.”

“An unannounced fire drill was not held during the months of January 2024 and August 2024.”

“The fire drill record for the drill conducted on 4/30/24 was incomplete and did not include all required information as specified in the regulation.”

“The home served residents requiring 93 gallons of emergency drinking water but had only 38 gallons available. The home did not have a contract with a local bottled water supplier.”

“Direct care staff person hired after April 24, 2006, was providing unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test.”

“A bottle of Medline Remedy antifungal powder labeled to keep out of reach of children was unlocked, unattended, and accessible to all residents in the Birchwood neighborhood. This was a repeated violation from previous inspections.”

“An approximate 2-inch accumulation of lint was found in the lint traps of the dryers in the Dogwood and Aspen neighborhoods, creating a fire hazard.”

“The home provided Resident 4's spouse with a verbal 30-day discharge notice but failed to provide a required 30-day advance written notice to the resident or the resident's designated person.”

“A resident was physically abused by another resident who held their arm tightly causing pain, and subsequently hit a third resident in the face resulting in bruising. This was a repeated violation from prior incidents on 7/2/24 and 11/28/23.”

“Staff Member A had not completed a required criminal background check at the time of hire.”

“Resident 1's assessment did not reflect significant changes in the resident's condition, despite documented aggressive incidents and hospitalization for agitation and combativeness occurring between the assessment date and inspection.”

“The entire home is a Secure Dementia Care Unit with key-locking devices at the front door, but directions for operating the front locking mechanism were not conspicuously posted near the front door.”

“Resident #1 was found hitting Resident #2 multiple times in the arm with a wet floor sign. Additionally, Resident #3 was observed holding Resident #4 against the wall with both hands around the neck and chest area. This is a repeated violation from 11/28/2023.”

“The door to the Spa Room in Hall D was unlocked and open. A spray bottle of Hillyard Suprox Glass and Floor Peroxide Cleaner was present in one of the closets, which requires calling poison control if ingested. Not all residents have been assessed capable of recognizing and using poisons safely. This is a repeated violation from 11/28/2023.”

“A blue and white couch in the C hallway outside of room C2 was observed to have a stain and odor from feces, indicating unsanitary conditions.”

“The Spa Room in Hall D did not have toilet paper present at the time of inspection.”

“The violation description for outdated food is incomplete in the provided document text.”

“Resident 1 grabbed, twisted, and struck Resident 2. The facility failed to provide appropriate supervision and assistance to Resident 1 despite the resident's RASP indicating moderate supervision needs and fall risk status. This resulted in multiple unwitnessed falls on various dates causing injuries including skin tears, head trauma, and bruising.”

“On 11/16/23 during the 11:00pm to 7:00am shift with approximately 26 residents, no staff members on site were certified in CPR. On 11/25/23 during the 3:00pm and 11:00pm shifts with approximately 26 residents, no staff members on site were certified in CPR.”

“Poisonous materials were found in bathrooms of Residents 3, 4, and 5 who are all unable to safely use or avoid poisonous materials per their DME and RASP. Items included washcloths with warnings regarding ingestion and inhalation, perineal cleaner, toothpaste, and skin care products with poison control warnings.”

“An allegation of abuse was not reported to the Local Area Agency on Aging in a timely manner. Staff Member B witnessed Staff Member A strike a resident, but the report to the AAA was delayed beyond the required timeframe.”

“An incident involving an allegation of abuse was not reported to the Department within 24 hours as required. The report was submitted late compared to when the incident was discovered.”

“A resident was struck in the chest and arm by Staff Member A on two separate occasions. On the first date, Staff Member A struck the resident in the chest after being struck by the resident. On a subsequent date, Staff Member A struck the resident in the arm and shouted at the resident.”