Juniper Village at Monroeville.

“A resident reported that another resident entered their bedroom, got into their bed, and touched their breasts and pubic area over their clothing. Shortly after, the same resident reported that another resident entered their bedroom, exposed themselves, and began performing a sexual act in front of them.”

“The home discharged a resident without providing a 30-day advance written notice to the resident or their designated person.”

“A copy of 55 Pa. Code Chapter 2600 personal care home regulations was secured in a cabinet behind the main entrance reception area and was not posted in a conspicuous and public place in the home.”

“A privacy coding document from the 4/17/24 inspection containing 11 resident names, including resident #5, was posted in a binder and unattended on the desk of the main entrance reception area, violating resident record confidentiality. This was a repeat violation from 4/17/2024.”

“Two direct care staff persons (A and B), hired on 7/21, did not receive training on instructions on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan during the 2024 training year. This was a repeat violation from 4/17/2024.”

“Three emergency exit doors did not securely close into the doorframe and had to be physically pushed shut: near bedroom #302, near bedroom #320, and one of the double emergency exit doors in the main dining room.”

“Resident #3's bedside lamp was unplugged and inoperable, with no other source of lighting present that could be turned on/off at the bedside.”

“A copy of 55 Pa. Code Chapter 2600 personal care home regulations was secured in a cabinet behind the main entrance reception area and was not posted in a conspicuous and public place in the home.”

“A privacy coding document from the 4/17/24 inspection containing 11 resident names, including resident #5, was posted in a binder and unattended on the desk of the main entrance reception area, violating resident record confidentiality. This was a repeat violation from 4/17/2024.”

“Two direct care staff persons (A and B), hired on 7/21, did not receive training on instructions on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan during the 2024 training year. This was a repeat violation from 4/17/2024.”

“Three emergency exit doors did not securely close into the doorframe and had to be physically pushed shut: near bedroom #302, near bedroom #320, and one of the double emergency exit doors in the main dining room.”

“Resident #3's bedside lamp was unplugged and inoperable, with no other source of lighting present that could be turned on/off at the bedside.”

“Resident #2 prescribed medication to be taken every day as needed was administered by staff person A multiple times in one day on various dates, not in accordance with prescriber's orders.”

“Resident #3 prescribed medication for severe pain every 2 hours as needed was not available in the home for administration on the date of inspection.”

“Multiple discrepancies found between medication administration records (MAR) and narcotic count sheets for residents #2, #4, #5, #6, and #7. Medications documented on MAR were not documented on narcotic count sheets and vice versa, indicating incomplete and inaccurate documentation of controlled substance administration.”

“Medication administrations documented on narcotic count sheets for residents #2, #5, #6, and #7 were not documented on their medication administration records, and vice versa. Date and time of medication administration were not recorded at the time of administration as required.”

“Resident confidential information was not properly secured. A packing slip for a resident's medication order was left unlocked and unattended on a medication cart in the hallway. Additionally, confidential resident information including names of residents receiving hospice care and care needs were visible on a dry erase board in the staff Hub that could be seen from the hallway.”

“The home did not have a quality management plan in place as required.”

“Voice-controlled electronic devices (Alexa) were in use in residents' rooms without posted notification that the devices were in operation and may be recording conversations.”

“Two direct care staff members did not receive required annual training during 2023 in medication self-administration and instructions on meeting resident needs as described in preadmission screening forms, assessment tools, medical evaluations and support plans.”

“An Environmental Services Director without fire safety expert credentials or training has been providing annual fire safety training for the past 2 years. Additionally, two direct care staff members did not receive fire safety training from a qualified fire safety expert or trained trainer in the 2023 training year.”

“A resident's bed-mounted Halo style enabler bar was not well-secured and could be moved approximately 3 inches in both directions, creating an entrapment and fall hazard.”

“Hot water temperatures in resident rooms exceeded the maximum allowed temperature of 120°F. Temperature at sink in room 301 measured 126.1°F and at sink in room 303 measured 124.1°F.”

“Emergency telephone numbers including nearest hospital and fire department were not posted on or by telephones with outside lines.”

“The home failed to immediately report suspected sexual abuse allegations made by a resident on approximately 2/6/24. The resident made allegations of sexual abuse against direct care staff person A, which were witnessed by multiple staff and residents. The home did not report the allegations to the Area Agency on Aging until 2/7/24 at approximately 4:00 p.m., violating the requirement for immediate reporting of suspected abuse.”

“The home failed to report allegations of sexual abuse to the Department within 24 hours. The resident made sexual abuse allegations against direct care staff person A on approximately 2/6/24, witnessed by multiple staff and residents, but the home did not report to the Department until 2/7/24 at approximately 5:00 p.m.”

“Direct care staff person G was found sleeping during the overnight shift, resulting in failure to provide required assistance with activities of daily living. Multiple residents were found with soaked briefs indicating their toileting and incontinence care needs were not met as required by their assessments and support plans.”

“Direct care staff person G assigned to the overnight shift on the 3rd floor was found sleeping on the sofa in the TV room, violating the requirement that all direct care staff on duty must remain awake when 16 or more residents are present. The facility had 60 residents at the time of the violation.”

“An unlabeled plastic spray bottle containing yellow/green liquid was found in the bottom right cabinet under the sink in the memory care unit, violating the requirement that poisonous materials be stored in their original, labeled containers.”

“Two cans of Krylon spray paint were found unlocked, unattended, and accessible to residents in the secured dementia care unit's activity closet.”