Shenango Presbyterian Home.

“A resident fell outside the home and sustained a fracture, but the home did not submit an incident report to the Department within 24 hours as required.”

“Two staff members did not have documentation of annual 2024 fire safety training completed by a fire safety expert.”

“Multiple staff members interviewed, including staff person C, did not know the location of the first aid kit.”

“Fire drill records did not include the exit routes used, whether the alarm was operative, and whether any problems were encountered during the drills.”

“A resident was admitted but the in-person medical evaluation was not completed within 60 days prior to admission or 30 days after admission. Additionally, another resident's medical evaluation form was incomplete with the body positioning and movement section left blank.”

“A bottle of ear wax removal aid drops prescribed to a resident remained in the medication cart despite the medication being discontinued.”

“Staff person A yelled at a resident during a shower assistance incident, and this allegation of abuse was not reported to appropriate authorities until approximately 6:24 a.m., in violation of immediate reporting requirements under the Older Adult Protective Services Act.”

“Staff person A verbally abused a resident by yelling at the resident during a shower assistance incident when the resident became aggressive.”

“A resident prescribed a medication twice daily was not administered the medication on 4/27/2025 for both a.m. and p.m. doses on multiple days because the medication was not available in the home, resulting in failure to follow the prescriber's orders.”

“A steam table located in an unsecured cabinet in the secured dementia care unit's kitchen had an outside temperature of approximately 164 degrees Fahrenheit and was accessible to residents, exceeding the 120°F threshold for required protective guards or insulation.”

“Multiple undated food items were found in the secured dementia care unit's refrigerator, including zip lock bags of celery, cauliflower, and carrots, and a Tupperware container of peaches, creating a contamination risk.”

“Multiple undated food items were found in the main kitchen's walk-in freezer, including a bag of 50 cookie pucks, a large blue bag of mixed vegetables, and a small bag of diced peppers, violating the prohibition on using outdated or spoiled food.”

“Two residents' prescription medications had pharmacy labels with incorrect directions: one medication was labeled to take two soft gel tablets daily instead of one capsule daily, and another was labeled to take one tablet twice daily instead of once daily.”

“A magnetically locked exit on a unit had a posted magnetic lock code that was incorrect and could not be used to operate the locking mechanism, preventing proper emergency egress.”

“Staff person A alleged seeing staff person B roughly handling a resident on 6/28/24 at approximately 7:00 pm, but the home did not report the allegation of abuse to the local Area Agency on Aging until 7/3/24, failing to report immediately as required.”

“On 6/28/24 at approximately 7:00 pm, staff person A alleged seeing staff person B roughly handling a resident. However, staff person B continued to work multiple shifts between 7/9/24 and 7/29/24 without being suspended or placed on a plan of supervision, and the department was not immediately notified.”

“An allegation of abuse involving staff person B roughly handling a resident on 6/28/24 at approximately 7:00 pm was not reported to the Department's personal care home regional office within 24 hours; the report was not made until 7/3/24.”

“Direct care staff person A, hired on an unspecified date, began providing unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test, which were not completed until 8/1/2024.”

“Resident's most recent assessment of care needs on record was not current per regulatory requirements for annual assessments.”

“Staff training records for direct care staff persons A, B, and C did not include the date and length of training for any trainings completed between 11/1/23 and 12/31/23.”

“Resident medication administration record did not include the initials of the staff person who administered the medication on the date inspected.”

“Resident support plan was completed on 8/21/22 but the resident and assessor did not sign and date the support plan until 11/28/23, failing to ensure timely signatures from participants in support plan development.”

“Staff person A did not receive training in medication self-administration or instruction on meeting residents' needs as described in the preadmission screening form, assessment tool, medical evaluation and support plan during training year 1/1/22 - 12/31/22.”

“Staff person A did not receive annual training in fire safety completed by a fire safety expert, emergency preparedness procedures, recognition and response to crises and emergency situations, resident rights, or The Older Adult Protective Services Act during training year 1/1/22 - 12/31/22.”

“The home's record of staff training for staff person A does not include source, content or length for training year 1/1/22 - 1/31/22.”

“Two spray bottles of X heavy duty multi surface cleaner and one spray bottle of disinfectant cleaner RCT concentrate with labels indicating "Contact Poison Control if swallowed" were unlocked, unattended, and accessible to residents in the cabinet under the sink in the Woodside Secure Dementia Care Unit kitchenette. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“On 10/18/23 at 10:10 a.m., there was a 1/4 full, uncovered, unattended trash can in the common women's bathroom in the 1st floor hallway. On 10/18/23 at 11:45 a.m., there were four 55-gallon trash cans in the main kitchen which were ¼ to ¾ full with lids having an 8" diameter hole cut in them.”

“On 10/18/23 at 10:20 a.m., there were no emergency telephone numbers including the nearest hospital and fire department on or by the telephone in the pantry kitchenette on the 1st floor. On 10/18/23 at 12:10 p.m., there were no emergency telephone numbers including the nearest hospital and fire department on or by the telephone in the ground floor staff dining room.”