Discovery Commons Bethel Park.

“A bedside mobility device affixed to resident #1's bed had an opening approximately ten inches wide by five inches high, presenting a hazard of limb entanglement or entrapment.”

“Emergency telephone numbers for the nearest hospital, police department, fire department, ambulance, poison control, local emergency management and personal care home complaint hotline were not posted on or near the telephone in the home's kitchen.”

“There was no thermometer in the ice cream freezer of the home's kitchen and the temperature could not be measured. A thermometer was subsequently placed and the freezer temperature was measured at negative two degrees Fahrenheit.”

“One of two medical evaluations provided for resident #2 was missing vital resident details including weight, pulse rate, blood pressure and temperature. The second evaluation was missing the resident's height measurement.”

“The pharmacy label for resident #3's Ondansetron 4mg tablet indicated an incorrect dosing interval of every 8 hours when the prescription required every 6 hours as needed.”

“Resident #4's annual assessment did not include an assessment for agitation that was indicated on the prescriber's orders attached to the resident's annual medical evaluation.”

“Hot water temperature at the sink in bedroom 251 measured 122.9 degrees Fahrenheit, exceeding the maximum allowable temperature of 120°F.”

“Uncovered trash cans were found in a shared bathroom (bedroom 335) and shared kitchenette, allowing potential insect and rodent penetration. This was a repeat violation from February 22, 2024.”

“The entire exterior walkway from the emergency egress route from the 1st floor personal care 'high side' door was covered in approximately 3-4 inches of snow, creating a safety hazard.”

“Fire drill evacuation time of twelve minutes exceeded the home's maximum safe evacuation time of ten minutes. Additionally, during a fire drill on 11/13/24, only 77 of 80 residents present were evacuated.”

“The support plan for Resident #1, admitted to hospice services, does not document the type and frequency of services provided by the hospice agency. This was a repeat violation from June 24, 2024.”

“Bedroom 108 did not have a light bulb in the bedside lamp, leaving the resident without an operable source of lighting that could be turned on at bedside.”

“A physician ordered a splint for resident #1's right hand to be worn in the morning and removed at bedtime for three weeks as of 8/28/24, but staff was unaware of the order and the splint was never used. This is a repeat violation occurring on 9/18/24, 8/26/24, 5/9/24, 3/19/24, 2/22/24, and 1/22/24.”

“Staff person A was observed on nanny camera using physical force to reposition a dementia resident during incontinence care, grabbing the resident's wrist and leaving the resident partially nude with clothing twisted around neck. This constituted physical abuse and mistreatment of a vulnerable resident.”

“Resident #2's ABHR medication label indicated application to wrist or neck area, but the prescription ordered application to wrist or neck area with different dosing instructions. Lorazepam 2mg/ml label did not include the route of administration as required.”

“Resident #2's Lorazepam medication administration record did not include the route of administration. Resident #3's ABH Cream MAR contained incomplete and inaccurate information regarding the medication form and application method.”

“Resident #3 was ordered ABH Cream to be applied topically to neck or wrist twice daily, but on 9/11/24 at approximately 8:00 a.m., direct care staff person B administered the medication orally instead of applying it topically as prescribed.”

“Staff member left the facility without administering morning medications to 41 residents on 8/4/24. The home did not report this incident to the Department until 8/6/24, failing to meet the required 24-hour reporting timeframe.”

“A binder containing narcotic medication information and resident personal information for multiple residents was unlocked, unattended, and accessible on top of the medication cart in a bedroom hallway. This is a repeat violation from 2/22/24.”

“The home served 108 residents including 47 with mobility needs and 30 in the secured dementia care unit, but only had 3 staff persons working overnight from 10:39 p.m. to 5:45 a.m. This inadequate staffing is insufficient to safely evacuate residents in an emergency.”

“With 108 residents in the home, the facility is required to have at least three staff persons certified in first aid and CPR present at all times. However, only two certified staff were on duty overnight from 10:39 p.m. to 5:45 a.m. on 6/15/24-6/16/24.”

“Resident #4 was prescribed Triple Antibiotic ointment for 10 days beginning 7/23/24, but the medication was still stored in the medication cart on 8/26/24 after the prescription period had expired. This is a repeat violation from previous inspections.”

“Resident #1's ordered medications (Methocarbamol, Albuterol HFA, and Tetrabenazine) were not available in the home on 8/26/24. Additionally, 60 tablets of Hydrocodone-Acetaminophen prescribed to resident #3 and delivered by pharmacy on 6/6/24 were discovered missing during the narcotic count on 6/7/24. These are repeat violations.”

“The home failed to follow prescriber's orders for multiple residents, including not administering prescribed medications, administering wrong doses, and not conducting prescribed blood glucose checks due to unavailable medications. This is a repeat violation.”

“Multiple discontinued medications were stored in medication carts and on nurses' station counters, including medications for residents no longer served in the home. Only current prescriptions should be kept in the home. This is a repeat violation.”

“Pharmacy labels on multiple residents' medications did not accurately reflect the prescribed dosage and instructions for administration, including incorrect frequency and dosage amounts. This is a repeat violation.”

“Multiple residents' glucometers were not calibrated to the correct date and time, and blood sugar readings were not properly documented on the medication administration record. This is a repeat violation.”

“Medications were signed off as administered but were not actually given to residents due to unavailability. Staff falsified medication administration records by documenting doses given when medications were not present in the medication cart. This is a repeat violation.”

“Resident #1's medical evaluation was signed as completed but the evaluation date was blank, and another medical evaluation was not completed until a later date. This is a repeat violation.”

“Medications were administered but not documented in the medication administration record at the time of administration. Resident #1's prescribed medication was signed off on the narcotic sheet but not logged in the eMAR. Resident #2's oxygen was administered but not logged on the eMAR.”

“Prescribed medications were not administered to residents as ordered by the prescriber. Resident #1 did not receive a prescribed tablet, and Resident #2 did not receive a prescribed capsule. This is a repeat violation from 6/27/23.”

“Medication administration training records were incomplete. Training for direct care staff person D was not fully dated by the instructor or signed and dated by the student. The annual practicum for staff person E was dated only as "12/23" without specifying the complete date the practicum was successfully passed.”

“Violation of section 234(a) regarding facility operations or management.”

“Violation of section 234(d) regarding facility requirements.”

“Violation of section 183(d) regarding resident record requirements.”

“Violation of section 184(a) regarding resident assessment or evaluation.”

“Violation of section 185(a) regarding resident care planning.”

“Violation of section 187(d) regarding documentation or reporting requirements.”

“Violation of section 183(e) regarding resident record maintenance.”

“Violation of section 187(a) regarding documentation requirements.”

“Violation of section 191 regarding resident care or facility operations.”

“Violation of section 225(a) regarding personnel requirements.”

“Violation of section 225(c) regarding staff qualifications or training.”

“Violation of section 227(a) regarding staff training requirements.”

“Violation of section 227(c) regarding staff training documentation or completion.”

“Violation of section 227(g) regarding training requirements or records.”

“Violation of section 231(b) regarding resident supervision or protection.”

“Violation of section 231(e) regarding resident safety or protection measures.”

“Staff person physically abused a resident by smacking their hand away hard, roughly grabbing them by the wrists, and pulling their ear so forcefully that the earlobe became detached, resulting in hospitalization. The incident was not immediately reported to the Area Office on Aging; reporting occurred approximately 5.5 hours after the initial incident at 7:30 p.m. instead of immediately.”

“Violation of section 17 related to facility operations or management.”

“Violation of section 25(b) regarding facility requirements.”

“Violation of section 141(b)(1) regarding resident care or services.”

“Violation of section 17 related to facility operations or management.”

“Staff person physically abused a resident by smacking their hand away hard, roughly grabbing them by the wrists, and pulling their ear so forcefully that the earlobe became detached, resulting in hospitalization. The incident was not immediately reported to the Area Office on Aging; reporting occurred approximately 5.5 hours after the initial incident at 7:30 p.m. instead of immediately.”

“Violation of section 25(b) regarding facility requirements.”

“Violation of section 141(b)(1) regarding resident care or services.”

“Violation of section 183(d) regarding resident record requirements.”

“Violation of section 184(a) regarding resident assessment or evaluation.”

“Violation of section 185(a) regarding resident care planning.”

“Violation of section 187(d) regarding documentation or reporting requirements.”

“Violation of section 183(e) regarding resident record maintenance.”

“Violation of section 187(a) regarding documentation requirements.”

“Violation of section 191 regarding resident care or facility operations.”

“Violation of section 225(a) regarding personnel requirements.”

“Violation of section 225(c) regarding staff qualifications or training.”

“Violation of section 227(a) regarding staff training requirements.”

“Violation of section 227(c) regarding staff training documentation or completion.”

“Violation of section 227(g) regarding training requirements or records.”

“Violation of section 231(b) regarding resident supervision or protection.”

“Violation of section 231(e) regarding resident safety or protection measures.”

“Violation of section 234(a) regarding facility operations or management.”

“Violation of section 234(d) regarding facility requirements.”

“The administrator or designee failed to provide immediate access to resident records upon request by Department agents on multiple dates (3/24/23, 4/3/23, and 4/5/23). Resident medical evaluations, assessments, support plans, demographic information, and staffing schedules were not provided.”

“Numerous medication errors involving residents #2, #3, #10, and #12 occurred during March 2023 but were not reported to the Department within 24 hours as required. This is a repeat violation from 8/1/2022.”