The Terrace at Chestnut Hill.

“Resident #1's medication record did not include a current list of medications. The record listed 5-mg Lorazepam tablets that were not in the resident's room and which the resident denied ever having. Additionally, the resident had two prescription medications (Ketoconazole cream 2% and Nitroglycerin 0.4% ointment) and three over-the-counter medications (Tylenol 500 mg, Claritin 10 mg, and Loratadine 10 mg) that were not on the medication list.”

“The pharmacy label for resident #3's polyethylene glycol contained incorrect instructions. The label stated to pour one capful (17g) into 8 ounces of water once daily, but the medication administration record indicated the correct instructions were to pour the dose into 4-6 ounces of liquid.”

“Unsanitary conditions were observed during safety walk-through: couch in memory care #2 was unclean with food stains, and arms of blue floral print chair were soiled with stains.”

“The outdoor patio area had multiple tripping hazards including an overturned table, umbrella stand with portion sticking up, and an overturned umbrella with the middle rod facing toward the sky.”

“The side of the oven between the cooktop and the deep fryer was covered in grease and grime, posing a fire hazard.”

“A resident witnessed two residents fist fighting and pushing each other in an elevator. One resident fell out of the elevator onto the floor after being pushed and was transported to the hospital with a hip fracture diagnosis. The facility failed to prevent physical abuse and mistreatment between residents.”

“A resident's medical evaluation dated 12/29/2023 documented medical diagnoses, but the support plan dated 2/13/2024 did not document how these medical needs would be met. This was a repeated violation from 10/16/2023.”

“An unlabeled, undated container of juice was found in the Memory Care kitchenette refrigerator.”

“An unlabeled and undistinguishable bar of soap was unlocked, unattended, and accessible to residents in Memory Care Room. Not all residents were assessed as capable of safely recognizing and using poisons.”

“The stairwell to exit 4 near Room was dark with a non-operable emergency light and non-working ceiling light fixture, creating a safety hazard for residents including those with vision impairments.”

“The rubber seal at the bottom of the refrigerator in the Memory Care kitchenette was falling off, creating a hazard.”

“Two loose pills were found in the Medication Cart serving the 2nd and 3rd floor, and tape was found on the back of a bubble pack for a resident's prescription tablet in spot 9.”

“Suspected abuse of a resident (resident 1 cut resident 2 with a broken vase) was not reported to the local area agency on aging as required by the Older Adult Protective Services Act.”

“Multiple insulin medication errors for resident 3 were not reported to the Department within 24 hours. Resident received incorrect doses based on blood sugar readings and sliding scale orders on multiple dates.”

“Resident 1 physically abused resident 2 by cutting them with a broken vase, resulting in a laceration requiring hospitalization. Resident 1 exhibited documented aggressive behavior toward staff and other residents, including threatening with a butter knife, but was not placed on 1:1 supervision until after the incident. RASP assessment did not include agitation or aggression evaluation.”

“Medication was administered to a resident by staff in a common area with other residents present, violating privacy requirements.”

“Hot water in room 302 had low water pressure on 10/17/23, failing to meet requirements for hot and cold water under pressure.”

“Toilet in the second-floor women's bathroom was clogged and would not flush on 10/16/23, creating a non-functional fixture.”

“No toilet paper was available in the women's bathroom on the first floor on 10/17/23. This is a repeat violation from previous inspections.”

“Resident 1's medical evaluation was not completed annually as required by regulation.”

“The assessment for Resident 2 did not include the assessor's name, title, signature, or the date signed.”

“Resident 2 participated in the development of his/her support plan but did not sign the support plan as required.”