Elm Terrace Gardens.

“A resident was denied dinner and treated disrespectfully by staff. When the resident rang their call bell multiple times requesting dinner at 5:45 pm, 5:52 pm, and 5:57 pm, staff person A told the resident "Don't you dare push that call button again" and stated "And you're not going to, either," then left the room without providing a meal.”

“Direct care staff person B did not receive required annual training on instruction on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan during training year 2025.”

“Staff person C failed to identify the correct resident when administering medications, resulting in a resident receiving medications prescribed for another resident. The resident required hospital treatment due to adverse reactions from receiving the wrong medication.”

“Two medication administration errors occurred. First, staff person C administered several medications prescribed for one resident to a different resident in error, resulting in the resident being admitted to the hospital with altered mental status. Second, staff person D left a medication cup containing one resident's medication on a table near another resident's recliner, and that resident ingested the half-tablet mistakenly believing it was their own medication.”

“Assignment sheets containing resident information were found on top of the 4th floor medication cart unlocked, unattended, and accessible, compromising record confidentiality.”

“Medication administration records did not include the initials of the staff person who administered narcotic medications on two separate occasions, despite the narcotic sheets being signed out and counts being deducted.”

“A resident's prescribed medication was held without consulting the prescribing doctor, contrary to prescriber's orders which specified parameters for when the medication should be held.”

“The home failed to report to the Department within 24 hours that a resident had not been receiving prescribed Ibrance tablets as directed.”

“A resident unable to self-administer medication missed 63 doses of prescribed Ibrance (a cancer medication) over several months due to staff failure to follow medication policies and administer the medication. The medication was stored unlocked in an unsecured cabinet, and the home did not report the medication errors to the Department. Missing doses could affect the resident's health and lifespan.”

“A resident's medical evaluation dated 03/21/25 had an incomplete medication listing, missing pages from an 8-page addendum. Specifically, the resident's prescription for Ibrance was excluded from the medication list.”

“A five-month supply of a resident's Ibrance tablets was stored unlocked, unattended, and accessible in an unsecured medicine cabinet in the medication room.”

“The home failed to follow the prescriber's orders for a resident prescribed Ibrance on a 28-day cycle (21 days on, 7 days off). The resident did not receive the medication for an extended period, missing 63 pills, and also missed 21 pills in June 2025.”

“Five direct care staff persons (A, B, C, D, and E) do not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required.”

“The home failed to report suspected abuse to the local area agency on aging when a resident's family reported that money was missing from the resident's wallet kept in the resident's dresser.”

“The resident's assessment and support plan required frequent staff checks of the resident's wander guard and chair alarm placement due to the resident's wandering behaviors and exit-seeking attempts. The home failed to provide or document this required supervision on specified dates.”

“A resident requiring extensive supervision and at risk for elopement was left unattended after being transported to the dining room. The resident subsequently fell down stairs, suffering a subdural hemorrhage. The resident died following hospitalization. The home had been advised of the resident's elopement risk and the need for placement in a secured dementia care unit, but the power of attorney declined this placement. The home's supervision plan did not specify frequency of required supervision checks.”

“A resident participated in the development of a support plan on a specified date but was unable to sign the support plan. The required notation of inability to sign was not documented.”

“Binders containing resident hospice information, Accu-Chek information, and resident lab work were observed unlocked, unattended, and accessible on the 3rd-floor nurses station counter, accessible to any visitor or non-medical staff, violating resident record confidentiality requirements.”

“Resident #1, identified as requiring extensive supervision due to elopement history and support plan indicating safety checks and WanderGuard pendant use, did not receive required supervision assistance. The resident eloped from the SDCU and was found approximately 1 mile away; staff assigned to the SDCU area were in an office with a closed door and could not hear the alarm, remaining unaware of the elopement.”

“Resident #1, identified as an elopement risk in support plan and preadmission screening, eloped from the SDCU through a 7th Street fire stairwell exit with delayed egress bars. The resident was not found by responding staff and was discovered approximately 1 mile away in a parking lot. Staff were unaware of the alarm due to being in closed offices, and the alarm notification system failed to alert staff on their communication devices. The resident was exposed to cold weather (47 degrees F) and dangerous traffic conditions near a busy main road and train station.”

“Staff member grabbed resident by pants and lowered them into wheelchair against resident's wishes, then tapped resident on shoulder and stated 'if you hit me, I hit you back' in response to resident punching staff member. This violated the requirement to treat residents with dignity and respect.”

“A resident's prescription medication blister pack was punctured in slot 37 and taped over, violating proper storage requirements for medications under proper conditions of sanitation and in accordance with manufacturer's instructions.”

“The home failed to implement positive interventions to modify or eliminate a resident's aggressive behavior. Staff did not follow the established care plan that required approaching calmly, giving choices about care times, re-approaching while explaining steps, and calling the resident's spouse if needed. Staff members could not demonstrate de-escalation or redirection techniques.”

“Staff member A lowered a resident into their wheelchair by grabbing the back of the resident's pants as the resident was trying to independently sit, which constituted an improper physical restraint or restriction of the resident's movement.”

“Direct care staff person D began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test as required.”

“A red STOP sign reading 'Do not enter' was posted on the front door of the memory care unit on the 7th street side, which serves as an emergency egress. The sign presents an obstruction as it may cause persons to hesitate to use that door during an emergency.”

“A jewelry theft incident reported to staff was not reported to the local area agency on aging as required under the Older Adult Protective Services Act. An Act 13 form was not completed and submitted within the required timeframe.”

“Resident #1 reported missing jewelry from their apartment. Staff have master keys to resident apartments with no specific guidelines or policy regarding staff access. Additionally, on 05/21/2024, Staff Member B physically and verbally abused Resident #2 by forcefully pushing the resident from bed, kicking their legs, yelling at them, and refusing to assist them, resulting in the resident falling and remaining on the floor for approximately 45 minutes.”

“A voice activated electronic device was present in Resident #1's apartment without a notice posted on the door indicating the operation of the device and that audio may be inadvertently recorded, violating resident privacy rights.”

“Suspected abuse of a resident was not reported to the Department within the required timeframe. A staff member pushed a resident on 10/30/2023, causing a fall and shoulder pain. The incident was reported to staff within hours but was not reported to the Department until 10/31/2023 at 4:28 pm.”

“A resident was physically abused when a staff member pushed the resident's shoulder after the resident used a racial slur, causing the resident to fall from a rollator and experience pain and discomfort to the left shoulder. The incident occurred on 10/30/2023 in the dining room and was observed by another staff member.”

“A resident's assessment indicated minimal mobility assistance needs, but the resident's medical evaluation documented moderate mobility needs. The support plan did not accurately reflect the resident's actual mobility assistance requirements, particularly after the resident required additional assistance during healing.”

“A resident's support plan was not revised within 30 days following multiple falls and hospitalization. The resident experienced two falls on 9/5/2023, was hospitalized, and released, but the support plan did not address the multiple falls.”

“A resident's support plan did not document how the resident's medical need for moderate mobility assistance would be met, despite the medical evaluation indicating this need.”

“A resident who participated in the development of a support plan did not sign the plan, and there was no documentation indicating the resident was unable or refused to sign.”

“The home's regulation book was not posted in a conspicuous and public place in the home.”

“Refund checks for two deceased residents were not issued within 30 days of when their personal belongings were removed from their rooms, in violation of the Elder Care Payment Restitution Act requirements.”

“A resident fell and sustained serious injuries including fractures and head trauma after being exposed to COVID-19 through an unscreened visitor whose positive status was known. The resident was not placed on isolation/quarantine, not tested for COVID-19 despite symptoms and weakness, and was permitted to ambulate without required supervision or assistive device, resulting in the resident's death.”

“A clear plastic container containing medication plastic bags with resident private information was left on top of the medication cart on the 3rd floor, violating resident privacy rights.”

“The home does not have criminal background checks on file for two staff members who were hired.”

“Poisonous materials including cream and toothpaste with manufacturer warnings were unlocked, unattended, and accessible to a resident.”