The Birches at Newtown.

“Direct care staff persons did not receive required fire safety and emergency preparedness orientation on their first work day, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher use, smoke detectors/alarms, and emergency notification procedures.”

“Direct care staff person began providing unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test.”

“A can of Lysol was unlocked, unattended, and accessible to a resident in their room.”

“MiraLAX medication was unlocked, unattended, and accessible in a resident's room. The resident's support plan indicated the resident cannot self-administer medication.”

“Resident medications in blister packs had torn foil backing, including a tab medication with torn foil at pill #6 and a Chew tab with torn foil at pill #7, creating improper storage conditions not in accordance with manufacturer's instructions.”

“The administrator's list of staff persons does not include contracted agency staff and substitute staff.”

“The resident-home contract was not signed by the resident, with no indication the resident was given the opportunity to sign. This is a repeat violation.”

“A resident who had been assessed as incapable of self-administering medications was found to have access to and ingested a large quantity of acetaminophen (500 mg tablets) for which there was no doctor's order, and also accessed and ingested prescribed medication, resulting in hospitalization with a toxicity level of 51.8. The resident had prior suicide attempts and psychiatric consultation on file.”

“Direct care staff did not have their qualifications reviewed to ensure they meet regulatory requirements prior to working with residents. An audit is required to review all current employee records.”

“Direct care staff member hired on the noted date did not receive required fire safety orientation on their first work day, including evacuation procedures, staff duties during fire drills and emergency evacuation, designated meeting place, smoking safety procedures, location and use of fire extinguishers, smoke detectors and fire alarms, and telephone use for emergency services. This is a repeat violation.”

“Direct care staff member A began providing unsupervised ADL services without completion of required training including demonstration of job duties followed by supervised practice, and Department-approved direct care training course with competency test.”

“One round white pill was found loose in the medication cart, indicating improper storage of medications not in accordance with manufacturer's instructions and sanitation standards.”

“Resident prescribed anxiety medication (1 tab orally 3 times daily at 9am/12pm/5pm) did not receive doses at specified times. Additionally, resident prescribed blood pressure medication (0.5 tab orally daily at 2pm with hold order for SBP less than 110) did not have blood pressure reading documented and medication administration was not properly initialed on medication administration record.”

“Staff member B grabbed resident by the wrist and rushed them from the dining room at a fast pace, lifted the resident by the pants to make them stand, and rushed them to the common area while pulling the walker and making them walk faster, despite the resident not requiring assistance with ambulation per their support plan. This treatment lacked dignity and respect.”

“Two residents participated in the development of their support plans but did not sign the plans as required.”

“A resident's support plan did not address ambulation, despite the resident using a walker to ambulate according to their medical evaluation.”

“Resident medical evaluation did not include special health or dietary needs of the resident as required.”

“Resident's most recent assessment was not completed timely or contained documentation errors regarding assessment dates.”

“The resident-home contract was not signed by the resident as required. The contract must be signed by the administrator or designee, the resident, and the payer if different from the resident.”

“An uncovered bedside mobility device was installed on a resident's bed with openings measuring 15 inches wide by 7 inches high, exceeding FDA guidelines of 120mm (4¾ inches). The device was not securely attached to the bed frame and could be pulled away, creating a hazardous 6.5-inch gap.”

“Multiple poisonous materials including Pronamel Active Shield toothpaste, cleaner, Cetaphil, Crest toothpaste, and Clorox spray were found unlocked, unattended, and accessible in resident rooms in the SDCU. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“An uncovered metal container of cut zucchini was found in the main kitchen walk-in refrigerator at 2:22pm, violating food storage requirements for closed or sealed containers.”

“Prescription and over-the-counter medications were observed unlocked and accessible in a resident's room in the SDCU at approximately 2:10pm, in violation of requirements to keep medications in locked containers.”

“Multiple medication cards with punctured blister foils were observed in the SDCU medication cart (residents in slots #12, #9, #30, #8, and #5), exposing medications to contamination. Additionally, loose pills (one oblong white, one oblong yellow, one round orange) were found in the SDCU medication cart and one round white pill in the first floor medication cart.”

“A resident prescribed insulin before meals and at bedtime on a sliding scale was not checked and received no medication on two separate occasions at 7am and 11am. Another resident prescribed a topical medication twice daily did not receive their evening dose on one occasion.”

“Staff member heard another staff member bragging about a resident giving them money but did not report this incident to supervisory staff in a timely manner, violating the 24-hour reporting requirement for incidents.”

“A laptop computer with an unlocked, open screen displaying sensitive resident information including DNR status and medications was left unattended and accessible on a medication cart in the Secured Dementia Care Unit, violating resident record confidentiality requirements.”

“Two staff members accepted a monetary loan (check) from a resident to help pay for housing, which constitutes accepting cash from a resident in violation of abuse and mistreatment regulations and facility policy.”

“Poisonous materials including Colgate toothpaste and shave foam with warning labels were left unlocked, unattended, and accessible in a resident bathroom in the Secured Dementia Care Unit, despite residents not being assessed as capable of safely using or avoiding poisonous materials.”

“A resident's medical evaluation form was missing required documentation in two sections: (4) special health or dietary needs and (8) body positioning and movement stimulus, with these sections left blank.”

“Directions for operating the key-locking mechanism were not conspicuously posted near Exit door 20 from the Secured Dementia Care Unit, violating requirements for emergency egress device operation instructions.”

“The home's administrator, who resides in a different state, was subject to only a PA PATCH (state) background check but did not have a Federal Bureau of Investigation (FBI) check completed as required.”

“Home failed to immediately develop and implement a plan of supervision or suspend staff B after resident alleged abuse by that staff member. While staff A was suspended based on initial allegation, when resident later identified staff B as the perpetrator, the home did not take immediate supervisory or suspension action.”

“Resident-home contracts for residents #2, #3, and #4 were not signed by the residents, as required.”

“Resident #2's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, as required for direct care staff.”

“The home does not have documentation showing that staff persons D, E, and F had an orientation in general fire safety and emergency preparedness prior to or during their first work day, including evacuation procedures, staff duties, meeting places, smoking safety, fire extinguishers, smoke detectors and fire alarms, and emergency service notification.”

“Within 40 scheduled working hours, direct care staff, ancillary staff, substitute personnel and volunteers are required to have orientation including resident rights, emergency medical plan, and mandatory reporting of abuse. (Note: The violation description appears incomplete in the source document.)”

“Direct care staff person B did not receive training in safe management techniques or care for residents with mental illness or intellectual disability during the training year 1/1/2023-12/31/2023.”

“A memory care resident spilled hot soup and juice on themselves at lunch. Staff member A responded with verbal abuse, asking "Are you kidding me?" and "What the hell is wrong with you?", made a lunging motion toward the resident, and failed to assess the resident for burns or provide assistance.”

“Direct care staff member A could not provide evidence of possessing a high school diploma, GED, or active registration on the Pennsylvania nurse aide registry.”

“Direct care staff person A hired on an unspecified date began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.”

“Clorox Cleanup cleaning product with poison control label was found unlocked, unattended, and accessible to residents in the secure dementia unit laundry room. Not all residents were assessed as capable of safely recognizing and using poisonous materials.”