The Village at Lifequest.

“The residence suspended a staff member due to an allegation of resident abuse but allowed the staff member to return to work without developing or implementing a plan of supervision. The staff member was permitted to return to the night shift without the required supervision plan in place.”

“Video cameras installed in hallways captured resident room doors and resident/staff movements in and out of bedrooms and corridors, infringing on resident privacy. The camera captured the doors of at least three resident living units, violating the requirement to provide privacy during activities in resident areas.”

“A resident's medical evaluation was incomplete, lacking height and weight on the General Physical Examination section and missing TB test date on the Immunization History section. The evaluation did not include all 12 mandatory components required within 30 days of admission.”

“A resident reported that money was missing from their wallet stored in a nightstand drawer. The theft was reported to the Sales Director the following day, and the matter was referred to State Police for investigation.”

“Staff Person A, a Texas resident, began working but did not have a criminal background check completed by the PA State Police and FBI prior to their start date.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. The staff member had only a current CNA license from Ohio.”

“A resident reported to Department agents that they did not receive prescribed liquid potassium from approximately [date range] because the medication was not available at the facility. The residence failed to report this medication error incident to the Department within 24 hours as required.”

“On one date at approximately 10:30am, a resident's medication list was left unattended and accessible on top of the second floor medication cart in view of residents and visitors. On another date at approximately 11am, the narcotic control log was left unattended, unlocked, and accessible on top of the first floor medication cart to residents and visitors, violating record confidentiality requirements.”

“On approximately 9:50am, a strong odor was present in a resident's bedroom with a substance appearing to be dried feces observed around the toilet bowl and toilet seat in the bathroom, indicating unsanitary conditions.”

“A resident's most recent medical evaluation was completed on a date in 2024, with the previous evaluation completed in 2022, resulting in a gap exceeding the required annual medical evaluation schedule.”

“Weekly menus for upcoming weeks were not posted in a conspicuous and public place in the home as required. Only previous weeks' menus were posted near the first floor dining hall.”

“Medication cards with punctured blister foil were observed in resident medication storage with medication still present in the compromised packaging, which is an improper storage method that can result in medication error, lost medication, and possible contamination.”

“A resident's pharmacy label directed taking a medication at bedtime, but the resident's November 2024 Medication Administration record and current physician order specified once daily at 9am, creating a discrepancy in medication labeling and administration instructions.”

“Several as-needed medications prescribed to a resident were not available in the residence on 11/7/24, including nasal spray, topical ointment, capsules, and lozenges, indicating inadequate medication storage and distribution procedures.”

“Two residents reported missing cash from their rooms. One resident had money in a drawer and purse that disappeared between specific dates; another resident had money in a bank envelope in their walker basket that went missing. Both residents had access to lockboxes or locking drawers but were unfamiliar with their use or did not utilize them. This constitutes neglect as residents' financial belongings were not adequately safeguarded.”

“Residence exceeded the maximum safe evacuation time of 8 minutes 30 seconds on two occasions: 8/18/2022 (22 minutes) and 6/20/2023 (11 minutes 30 seconds).”

“Fire drill records were incomplete. The 4/10/2023 drill was missing evacuation route and time. The 5/26/2023 drill was missing evacuation time, route, and number of residents present. The 6/20/2023 drill was missing evacuation route and number of residents evacuated.”

“Resident #1 who self-administers medication had an outdated medication list in their record. The record listed Gabapentin 300-MG once daily, but a prescription filled 7/7/2023 specified twice daily dosing.”

“Prescribed as-needed medications were not available in the residence. Resident #2's bisacodyl suppositories and docusate sodium capsules were unavailable. Resident #3's Geri-Tussin Syrup was unavailable.”

“During 12 fire drills between 7/14/2022 and 6/20/2023, residents did not evacuate to a designated meeting place away from the building or within the fire-safe area.”