Atria Center City.

“Poisonous materials (deodorant stick and toothpaste tube with manufacturer warnings) were unlocked, unattended, and accessible in a resident's medicine cabinet. The resident's room door was also unlocked, and the resident had not been assessed as capable of safely recognizing and using poisons.”

“The rear hallway leading to the dumpster area was scattered with loose trash, full black trash bags, cardboard boxes, and discarded medical equipment. Several large green trash bins in the dumpster area lacked lids or had lids that were not closed.”

“Hot water temperature in the showers of two residents' apartments measured 69 degrees Fahrenheit, preventing the residents from showering. The facility lacked adequate hot water pressure in bathrooms.”

“Emergency telephone numbers (hospital, police, fire, ambulance, poison control, local emergency management, and personal care home complaint hotline) were not posted on or by the telephone near the Life Guidance kitchen.”

“Resident property (two iPads) was stolen by a direct care staff member working in the secure dementia care unit. The staff member had access to the residents' apartment, denied the theft when confronted, failed to provide a written statement as requested, and was subsequently terminated.”

“Telephone numbers of the Department's personal care home regional office, local ombudsman, protective services unit, Disability Rights Pennsylvania, local law enforcement, Commonwealth Information Center, and complaint hotline were not posted in a conspicuous and public place in the secure dementia care unit.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry; the staff person's nurse aide registry had expired as of 12/10/2024.”

“Direct care staff person B did not receive training in medication self-administration during the training year.”

“Staff person A administered prescription medications to a resident without having completed the medication administration training as specified in § 2600.190, and without meeting the qualifications to provide direct care (expired nurse aide certification).”

“No carbon monoxide detector was installed in the kitchen which uses gas equipment. Per the Care Facility Carbon Monoxide Alarms Standards Act, carbon monoxide alarms must be installed in proximity of, but not less than 15 feet from any fossil-fuel burning device or appliance.”

“Resident #1 moved into the home on 12/25 but signed the Residency Agreement on 01/13/25. Resident #2 moved into the home on 12/24 but signed the Residency Agreement on 12/09/24. Written resident-home contracts must be signed prior to admission or within 24 hours after admission.”

“The Residency Agreement dated 2023 for resident #5 was not signed by the resident. Contracts must be signed by the administrator or designee, the resident, and the payer if different from the resident.”

“On 12/09/2024 at 6:30am, resident #2, who requires 24-hour supervision and resides in the secured dementia care unit on the 2nd floor, was missing and observed exiting the home through the Race Street Exit at 6:41am. The resident was able to navigate two steep stairwells with a rollator, walk through the personal care neighborhood, and exit through the first floor exit door without detention or alarms alerting staff. The secure dementia unit alarm system was not functioning from 11/30/2024 at 11:39pm through 1/2/2025 at 7:38am, allowing the resident to elope without needed supervision.”

“Resident #1's most recent medical evaluation was not completed within the required annual timeframe, with the previous evaluation dated 11/27/2023 or earlier.”

“Discontinued medications were found in the home's medication cart for Resident #2, including tablets that were discontinued on undisclosed dates.”

“Pharmacy label for Resident #2's medication did not include the correct prescribed dosage and instructions for administration; label read 'Take 2 by mouth every day at 8 PM' when the physician's order was for 1 tablet daily at 8 PM.”

“Resident #2's medication administration record (MAR) for 2024 does not list diagnosis or purpose for medications administered.”

“Violation classified as Class II with a calculated fine of $645 based on 129 residents at inspection and $5 per day penalty.”

“Based on violations found during June 17, 2024 and August 5, 2024 inspections, the Department revoked the previous certificate of compliance (136570) dated December 2, 2023 to December 2, 2024 and issued a FIRST PROVISIONAL license.”

“Resident's most recent medical evaluation was completed on 4/11/2024, with the previous evaluation on 9/19/2022, exceeding the required annual interval. Another resident's most recent evaluation was on 11/17/2023, with the previous on 9/19/2022, also exceeding the annual requirement.”

“Resident self-administers medications and stores them in bedroom. Several unlocked and unattended medications, including alprazolam 1mg tablets, were observed in resident bedroom on 8/15/2024.”

“Resident self-administers medications but was unable to remember what pills had been taken and what pills should be taken on 8/15/2024. The resident's spouse was assisting with medications, indicating the resident was not capable of safely self-administering medications.”

“Resident #1's most recent medical evaluation was not completed annually as required. The evaluation was completed on 11/27/23, which did not meet the annual requirement.”

“Discontinued medications were found in the medication cart. Vitamin B-12 tablets prescribed for resident #2 were in the cart but discontinued on 6/3/24; Magnesium Oxide 500 MG tablets were in the cart but discontinued on 6/17/24 at 7:37 am.”

“Resident #2's Melatonin 3 MG pharmacy label did not include the correct prescribed dosage and instructions. The label read 'Take 2 by mouth every day at 8 PM' but the physician's order dated 5/29/24 was for 1 tablet by mouth daily at 8 pm.”

“Violation of administrative requirements. A civil money penalty of $645 per day was assessed based on a Class II violation with 129 census residents at inspection.”

“Resident #1's most recent medical evaluation was not completed annually as required. The evaluation was completed on 11/27/23, which did not meet the annual requirement.”

“Discontinued medications were found in the medication cart. Vitamin B-12 tablets prescribed for resident #2 were in the cart but discontinued on 6/3/24; Magnesium Oxide 500 MG tablets were in the cart but discontinued on 6/17/24 at 7:37 am.”

“Resident #2's Melatonin 3 MG pharmacy label did not include the correct prescribed dosage and instructions. The label read 'Take 2 by mouth every day at 8 PM' but the physician's order dated 5/29/24 was for 1 tablet by mouth daily at 8 pm.”

“Violation of administrative requirements. A civil money penalty of $645 per day was assessed based on a Class II violation with 129 census residents at inspection.”

“During training year 2022, staff person B did not receive required annual training in fire safety, emergency preparedness procedures, resident rights, the Older Adult Protective Services Act, and falls and accident prevention. Staff person C also did not receive required fire safety and other annual training.”

“A book containing residents' toileting schedule/checks was found unsecured in an unlocked memory care closet, violating record confidentiality requirements.”

“The resident-home contract for resident #1 was not signed by the resident.”

“Resident #1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Staff A, a medication technician, was observed administrating medications to a resident in the home's Bistro instead of in the resident's apartment, violating privacy requirements.”

“Direct care staff person B received only 2.5 hours of annual training during training year 2022, falling short of the required 12 hours.”

“Direct care staff person B did not receive required annual training topics including medication self-administration, instruction on meeting resident needs, infection control and hygiene, and personal care service needs during training year 2022.”